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ISSN 0020-1324-RECACP 


48th International Respiratory Congress 

Annual Convention & Exhibition 

October 5-8, 2002, Tampa, Florida 


Clinical Utility for Measures of Breatfilessness 

Neonatal Endotracheal Tube Size and Airway 


Huge Pulmonary Arteriovenous Fistula: Diagnosis 
and Treatment and an Unusual Complication of 

Anticipatory Use of Venoarterial ECMO for a High- 
Risk Interventional Cardiac Procedure 


Mechanical Ventilation Strategies: What's New and 
What's Worth Keeping? 


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At the AARC International Respiratory Congress, you'll have the opportunity to hear and meet 
the most renowned speakers in respiratory care. This is the meeting where the largest group of 
respiratory experts come to speak and to listen. Come hear: 

Donald F. Egan Scientific Lecture 
Dr. John B. Downs MD 

Dr. Downs will address the most controversial aspects of oxygen therapy. While possible 
adverse effects have generally been downplayed in recent years, new data suggest this may not 
be wise. Some conclusions may be surprising to many in respiratory care. 

New Horizons Symposium - A review of pulmonary function testing 

Neil Maclntyre MD, Robert Crapo MD, Paul Enright MD, Robert Hensen PhD 

Lots of Other Opportunities to learn from the best. . . 

Charles Durbin MD (airway management), Scott Epstein MD (NIPPV), Timothy Myers RRT 
(asthma management), Alex Adams RRT (critical care), Paul Selecky MD (end of life), Karen Stew- 
art RRT ( patient safety), James Stoller MD (protocols), Michael Weiss MD (nitric oxide), Richard 
Branson RRT (critical care), Thomas Kallstrom (indoor air quality), Ralf Fuhlen MD (spontaneous 
breathing), Giorgio Sotti MD (closed loop pressure support), Linda Peeno MD (managed care), 
Susan Blonshine RRT (diagnostic assessment), Deborah Cook MD (evidence-based practice), 
Joseph Lewarski RRT (home care) and many many more - over 150 presenters! 

We are the "gold standard" of respiratory care meetings worldwide. Here's why: 

• The lowest cost of continuing education per credit! 

• The largest and most impressive Exhibit Hall, featuring the most vendors AND the ability to 
buy right onsite. 

• The largest gathering of respiratory experts in the world. 

• The most diverse and dynamic series of lectures. 

• The largest presentation of original research by RTs. 

• The most opportunities for YOU to network with your peers. 

Don't miss this opportunity to attend the 
longest-running respiratory therapy gathering in history! 

October 5-8, 2002 • Tampa Bay, Florida 
48th Annual International Respiratory Congress 

For more information, visit 

and click on Tampa Bay. Or call 972-243-2272. 

American Association for Respiratory Care 

11030 Abies Lane, Dallas, TX 75229 

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Clinical Utility for Measures of Breathlessness 

hx nehiiriili L Ciilli'ii ditil Renuidelle RoJak — lmlkmainili\. IiuIihiki 

Relali()nship of Neonatal Endotracheal Tube Size and Airway Resistance 
/)\ Meiisii J Oca. Michael A Becker, Ronald E Decheri. 
ami Sleven M Dann — Ann Arh(n: Miclii)>an 



Huge Pulmonary Arteriovenous Fistula: Diagnosis and Treatment and 
an Unusual Complication of Embolization 

l>\ Oliver Krelschmar. Peter Ewerl. Hashim AhilnlKhaliq. Mustafa 
Hein: R Znrhriit;i;. Roland Het:er. and Peter E UniKe^Berlin. Germany 

Anticipatory Use of Venoarterial Extracorporeal Membrane Oxygenation 
for a High-Risk Interventional Cardiac Procedure 

/)V Tina li Carinichael. Edward P Walsh, and Stephen .1 Roth Boston. Mas.\achiisetts 



Mechanical Ventilation Strategies: What's New and What's Worth Keeping? 

In Dean R Hes.s — Boston. Massachnsetis 



It Hurts to Say "Hertz" 

hy Rohert L Chatlmrn— Cleveland. Ohio 

Clinician Perspective on Critical Thinking and Decision-Making 
h\ Glenn A Roberts — Macon. Geors;ia 

Is Critical Thinking a Luxury? 

/j\ Keith B Hopper — Marietta, Georj^ia 

responses to Roberts & Hopper by 

Thoimis V Hill — Ketterin)>. Ohio 

and by Shelley C Mishoe — Aujiiisla. Georgia 


R.A.L.E. Lung Sounds 3.0 CD-ROM 

reviewed by Robert L Wilkins—Loina Linda. California 

Shortness of Breath: A Guide to Better Living and Breathing, 6th ed 
(Ries AL. Bullock PJ, Larsen CA. Limberg TM, Myers R. Plister T. 
Sassi-Dambron DE. Sheldon JB) 

reviewed hv Bonnie /■' Eahv —Phoenix. .Arizona 

Radiologic Diagnosis of Diseases of the Chest (Mi.iller NL. 
Eraser RS. Colman NC. Pare PD) 

reviewed by Eric J Stent — Seattle, Washington 





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AARC Membership 
1103 Application 


Abstracts trom 
Other Journals 


Advertisers Index 
& Help Lines 




of Events 


Preparation Guide 




A Monthly Science Journal 
Established in 1956 

The Official Journal of the 

American Association for 

Respiratory Care 

CT Angiography of the Chest (Remy-J;irdin M. F^lmiiv J. Mayo JR. MuIIlm NL) 
ifvicwcil In Eric J Slern — Seatlle, Waslun{;l<iii 

Imaging ol' ihc Chest: A Teaching File (Mergo PJ, editor) 

revii'wi'tl hv Nisii Tli(><nii^.\ti\iaii — Si'ulllf. \V(i\ltini^[(Ht 

Medical Apphcations of Computer Modelling: The Respiratory System 
(Martonen TB. editor) 

;<i7(ir((/ h\ Micluul P Hlasuila — Secinle. Wcishint^lim 

Statistical Methods for Anaesthesia and Intensive Care (Myles PS. Gin T) 

reviewed by Wesley M Granger — Birmingham. Alabama 


2002 Abstracts 
Aulhoi' Index 







Congress Exhibitors I U 9 



OCTOBER 5-8, 2002 

This year's International Respiratory 

Congress in Tampa, Florida, promises 

to offer many unique cultural, educational, 

and other entertaining experiences to 

its attendees. Come to Tampa for one 

of the most breathtaking educational 

events of the year. Be sure to mark 

your 2002 calendar for the next AARC 

Congress, October 5-8, 2002. 

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Hiirhorview Medical Ccnlcr 
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Scalllc. \Vti\luiii;k)ii 


Richard D Branson RRT FAARC 
l'ni\Tr.\it\ of Cliu innaii 
Cincinnati. Ohio 

Dean R Hess PhD RRT FAARC 

Massachiisdts Ci-ncral Hospital 
Harvard University 
Boston. Massachusetts 

James K Stoller MD MSc FAARC 

I he Cleveland Clinic Foundation 
Clevelanil, Ohio 


Katherine Kreilkamp 


A Monthly Science Journal 
Established in 1956 

The Official Journal of the 

American Association for 

Respiratory Care 

Charles G Durbin Jr MD FAARC 

i'nncf •,ij\ of X'tji^ttmi 
Clunh'ttfwillc. \'ir{;initi 


Neil R Maclntyre MD FAARC 
Duke i'niversii\ 
Ptirham. North Carolina 

Alexander B Adams MPH RRT 

Regions Hospital 
St Paul. Minnesota 

Thomas A Barnes EdD RRT 

Norlhcastcni University 
Boston. Massachusetts 

Joshua O Bendilt MD 
University of Washington 
Seattle. Washington 

Michael J Bishop MD 
University of Washington 
Seattle. Washington 

Lliiis L Blanch MD PhD 

Hospital de Sabadell 
Sahadell. Spain 

Bartolome R Celli MD 

Tufts University 
Boston. Massachusetts 

Robert L Chatburn RRT 

University Hospitals of Cleveland 
Case Western Resene Universit\ 
Cleveland. Ohio 

Patrick J Dunne MEd RRT 

Health Care Productions 
Fullerton. California 

James B Fink MS RRT FAARC 

AeroGen Inc 

Mountain View. California 

John E Heffner MD 

Mediial University of South Carolina 
Charleston. Smith Carolina 

Mark J Heulilt MD FAARC 

University ol Arhuisas 
Little Rock. Arkansas 


Leonard D Hudson MD 

Universit}' of Washini-ion 
Seattle. Washington 

Robert M Kacmarek PhD RRT 

Massachusetts General Hospital 
Hairard University 
Boston, Massachusetts 

Richard H Kallet MS RRT 

San Francisco General Hospital 
University of Calif >rnia San Francisco 
San Francisco. California 

ELucy Kesier MBA RRT 

The Cleveland Clinic Foundation 
Cleveland. Ohio 

Max Kirmse MD 
University of Erlangen-Niirnherg 
Mohrendoif. Gennany 

Toshihiko Koga MD FAARC 

Koga Instituel for Medical Research 
Tokyo. Japan 

Marin H Kollet MD 

Washini;fon Uni\ersit\ 
St Louis, Missouri 

Constantine A Manthous MD 

Bridgeport Hospital 
Bridgeport. Connecticut 

John J Marini MD 

University of Minnesota 
St Paul. Minnesota 

Shelley C Mishoc PhD RRT 

Medical College of Georgia 
Augusta. Georgia 

Steven B Nelson MSc RRT 

Overland Park. Kansas 
Mayo Puhnonaiy Sen'ices 
Ro< luster. Minnesota 

Marcy F Petrini PhD 

University of Mississippi 
Jackson. Mississippi 

Joseph L Rau PhD RRT FAARC^ 

Geori;ia State University 
Atlanta. Georgia 

Catherine SH Sassoon MD 

University of California Irvine 
Ltmg Beach. California 

John W Shigeoka MD 

Veterans Administration Medical Center 

Salt Lake City. Utah 

Eric J Stern MD 

Harhoiriew Medical Center 
University of Washington 
Seattle. Washington 

Martin J Tobin MD 
Unola University 
Chica^^o. Illinois 

Jeftrev J Ward MEd 

Ma^o Medical Sclu>ol 
Rochester, Minnesota 

Robert LWilkins PhD RRT 

Lotna Linda University 
Loma Linda. California 


Gordon D Rubenfcld MD MSc 
University of Wasliin^ton 
Seattle. Waslnn^ton 

Hugh S Mjlhewson MD 
Joseph L Rau PhD RRT FAARC 
Driti> Ctipsitlv 

Charles n lr\ui PhD 

Grcgc L Ruppei MI:d RRT RPFT FAARC 

PhT Comer 

Richard D Bransiin RRT FAARC 
Rnben S Campbell RRT FAARf 
Kittreil\ie '\ Corner 

Steven B Nelson MSe 
RC Wel> Sites 

Jon Nilsestuen PhD RRT FAARC 
Ken Hargeti RRT 
Crapliics Corner 

Patricia Ann I^oorley MS RRT FAARC 
Charles C. Durbin Jr MD FAARC 
Te\t Your Ka,li,'lof;ii Skill 


Summaries of Pertinent Articles in Other Journals 

Editorials. Commentaries, and Reviews to Note 

New Treatments for Pulmonarj Arterial Hypertension — Hocper MM. Galie N, SimDnneau G. 
Rubin 1,1, .Am,! Rt-spn Cnl Carf Med 20(12 Ma\ I ;I6.S|9): 1209-1216. 

Major Radiation Kxposure — What to Kxpect and How to Respond — Meltler FA Jr. Voelz 
GL. N Engl J Med 2002 May 16;346(20):l.S.';4-l.'^fil. 

Pneunionology or Pneumology? An Etymologic Approach (editorial) — Ramoutsaki I. 
Ramoutsakis I. Bouros D. Chest 2002 May;121(5):138.'i-13S7. 

Noninvasive Ventilation: .\ Decade of Progress (editorial) — Elliiilt M. .Anibrosino N. Eur 
Respir J 2002 Apr;im4);_S,S7-.'SS9. 

Diagnosis and Management of Smallpox — Breman JG, Henderson DA. N Engl J Med 2002 

The Persistently Troublesome Cough — Irwin RS. Madison JM. Am J Respir Crit Care Med 
2002 Jun I; 163(11): 1 469- 1474. 

Paradoxical Physical Findings Descrihed by Kussmaul: Pulsus Paradoxus and Kussmaul's 

Sign (historical article)— Bilchick KC. Wise RA. Lancet 2002 Jun 1;3.^9(9321 ):1940-I942. 

The Pragmatics of Prone Positioning — Messerole E. Peine P. Wittkopp S. Marini JJ. Albert 
RK. Am J Respir Crit Care Med 2002 May 1 5; 16.'S( 10 1:1359-1363. 

When Increased Therapeutic Benefit Comes at Increased Cost (editorial ) — Wood AJ. N Engl 
J Med 2002 Jun 6;.U6( 23): 1819-1821. 

Response of Lung Volumes To Inhaled Salbutamol in a Large Popu- 
lation of Patients With Severe Hyperinflation — Newton MF. O'Don- 
nell DE. Forkert L. Chest 2002 Apr;121(4): 1042-lO.SO. 

OBJECTIVES: Current criteria use FEV| to assess bronchodilalor 
responsiveness, despite its insensilivity and inability to predict improve- 
ment in symptoms or exercise tolerance. Response in lung volumes 
remains largely unexplored even though volume parameters, such as 
inspiratory capacity (IC). closely correlate with functional improvements. 
Therefore, we assessed the response of lung volumes (i.e.. by IC. total 
lung capacity |TLC]. functional residual capacity |FRC]. residual volume 
[RV]. and FVC) to salbutamol and the relationship of these changes to 
improvements in the spirometry in these patients. DESIGN: A retrospec- 
tive revievK of data extracted from a large database of patients who were 
undergoing spirometry and static lung volume measurements before and 
after the administration of 200 microg salbutamol. PATIENTS: Patients 
with an FEV|/FVC ratio of < 859^ of predicted values were defined as 
being .severely hyperinflated (SH) if TLC was > 133% of predicted and as 
being moderately hyperintlated (MH) if TLC was 1 15 to 133% of pre- 
dicted. RESULTS: Two hundred eighty-one SH patients and 676 MH 
patients were identified. Salbutamol significantly reduced the mean (± 
SFM) TLC (SH patients. 222 ± 23 mL; MH patients. 150 ± 10 mL: p < 
0.001 ). FRC (SH patienis. 442 ± 26 mL; .MH patients. 260 ± 39 mL; p < 
0.001 1, and RV (SH patienis. 510 + 28 mL; MH patients. 3(K) ± 14 niL; p 
< 0,(M)l) and increased both the IC (SH patients. 220 ± 15 mL; MH 
patiems. 1 10 ± 11 ml.; p < 0.001 ) and FVC (SH patients, .336 ± 21 mL: 
MH patienis. 204 ± 13 niL; p < 0.001 ). FEV| improved in a minority of 
patients (SH patients. 33%: MH patients. 26%). but if lung volume mea- 
surements are also considered, the overall bronchodilalor response may 

improve to up to 76% of the SH group and up to 62% of the MH group. 
Changes in volumes correlated poorly with changes in maximal airflows. 
CONCLL'SIONS: Bronchodilators reduce hyperinflation. Measurements 
of lung volumes before and after bronchodilators add sensiti\ity «hen 
examining for bronchodilalor responsiveness. 

,\ Comparison of the \ alidity of Different Diagnostic Tests in .-\dults 
with Asthma — Hunter CJ. Brightling CE. Woltmann G. Wardlaw AJ. 
Pavord ID. Chest 2002 Apr;l2l(4):l05l-1057. 

STUDY OBJECTIVES: Diagnosing asthma is not always easy, and there 
are times when objective tests can be helpful. The extent to which these 
tests alter the probability of asthma depends on how much more com- 
monly the test result is positive in subjects with asthma compared to 
healthy subjecls and particularly subjects with conditions ihat Me com- 
monly confused with asthma. We set out to compare the sensitivity and 
specificity of different tests in this setting. DESIGN; Single-center, cross- 
sectional, observational study. SETTING: Teaching hospital. 
PATIENTS; Twenty-one healthy control subjects. 69 patients with 
asthma, and 20 subjects referred to the hospital with a diagnosis of 
asthma who were found to have alternative explanations for their symp- 
toms (i.e.. pseudoasthma). INTERVENTIONS: We measured metha- 
choline airw ay responsiv eness. the maximum w ithin-day peak expiratory 
tlow amplitude mean percentage (derived from twice-dailv readings for > 
2 weeks), the FEV|/FVC ratio, the percentage change in FEV| 10 min 
after the administration of 200 microg inhaled albuterol, and the differen- 
tial eosinophil count in blood and induced sputum. We derived normal 
ranges (from the 95% upper or lower limit for healthy subjects), sensitiv- 
ity, and spccificitv (ie. the percentage of subjects with pseudoasthma who 


Respiratory Care . September 2002 Vol 47 No 9 




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had neyalivc lest resulls). KliSlJl-rS; Miisl Icsts were less specific when 
the reference population was composed of subjects with conditions that 
can be confused with asthma. Mcthachohne airway responsiveness and 
the sputum differential eosinophil count were the most sensitive (9I'J 
and ll^ic. respectively! and specific l9(K/( and X()9f. respectively) tests. 
CONCLUSION: We conclude that methachnline airway responsiveness 
and the sputum ditfcrential eosinophil couni are ihc most useful objective 
tests in palieiils w ith mild asthma. 

Comparison of the Ktllcacy, Toltrability. and Safety of Formoterol 
Dry Powder and Oral, Slow-Release Theophylline in the Treatment 
of COPD— Rossi A. Knstutek P, Levine BE. Thomson MH. Till D. Kot- 
tal<is J. Delia Cioppa G; Formoterol in Chronic Obstructive Pulmonary 
Disease (FICOPDl II Study Group. Chest :fK)2 Apr;l2l(4):in58-I06y. 

STUDY OBJECTIVE: To compare the efficacy, tolerability. and safely 
of therapy with formoterol and oral slow-release theophylline (THEO) in 
patients w ith COPD. DESIGN: A randomized, parallel-group study, with 
double-blind arms for formoterol and placebo (PL) and an open arm for 
oral slow-release THEO administered in individual doses on the basis of 
plasma concentrations. SETTING: Eighty-one centers worldwide. 
PATIENTS: Eight hundred fifty-four patients with symptomatic COPD. 
INTERVENTION: Comparison of twice-daily inhaled formoterol dry 
powder ( 12 or 24 microg). PL. and THEO (individualized doses) over 12 
months. MEASUREMENTS AND RESULTS: Compared to PL. doses 
of formoterol and THEO both significantly improved the area under the 
curve for FEV| measured over a period of 12 h following the morning 
dose of study medication at 3 and 12 months (p < 0.001 for all compar- 
isons). Therapy with formoterol, 1 2 microg. was significantly more effec- 
tive than that with THEO (p < 0.026). Formoterol significantly reduced 
the percentage of "bad days'" (i,e,. days with at least two individual symp- 
tom scores > 2 and/or a reduction in peak expiratory How from a baseline 
of > IWc: p < 0.035 vs. PL and THEO i, and the use of salbutamol rescue 
medication (p < 0.003 vs PL) over the whole treatment period, while the 
effect of THEO was similar to that of PL. Therapy with formoterol and 
THEO was more effective than PL at improving quality of life for > 12 
months (p < 0.030). Treatment-related adverse events and discontinua- 
tions were more frequent among patients receiving THEO than among 
those receiving formoterol. CONCLUSIONS: Long-term treatment with 
inhaled formoterol dry powder is more effective and better tolerated than 
treatment with therapeutically appropriate doses of oral slow-release 
THEO in symptomatic patients with COPD. 

Megestrol Acetate Stimulates Weight Gain and Ventilation in Under- 
weight COPD Patients — Weisberg J. Wanger J. Olson J, Streit B. Foga- 
rty C. Martin T, Casabun R. Chest 2002 Apr: 121(4): 1070- 1078. 

STUDY OBJECTIVES: To assess the effect of megestrol acetate (MA), a 
progestational appetite stimulant commonly used in patients with AIDS 
and cancer, on body weight and composition, respiratory muscle strength. 
arterial blood gas levels, and subjective perceptions in COPD patients. 
DESIGN AND SETTING: Prospective, double-blind, randomized, 
placebo-controlled trial conducted on an outpatient basis at 18 sites. 
PATIENTS: Underweight (< 9.S';; ideal body weight) COPD patients > 
40 years old. INTERVENTIONS: Either MA, 800 mg/d oral suspension, 
or placebo at a 1:1 ratio for 8 weeks, RESULTS: Of 145 randomized 
patients (bY/c men), 128 patients completed the trial. Body weight 
increased by 3,2 kg in the MA group and 0.7 kg in the placebo group (p < 
0.001). Anthropometric and dual-energy radiograph absorptiometry 
assessments confirmed that weight gain was mainly fat. Spirometry and 
maximal voluntary ventilation showed mi significant changes from base- 
line in either group, and the difference in the change in maximum inspira- 
tory pressure between groups was not signillcant. The (i-min walk dis- 
lances did not differ statistically between groups at week 2 and week 4. 
but were greater in the placebo group at week 8 (p = 0.01 2 1. Consistent 

with the known ability of MA to sliinulale ventilation. Pjco-. decreased 
(4.6 mm Hg. p < 0.(K)I ) and PaOj increased (2.8 mm Hg. p < 0.04) in the 
MA group. Questionnaires revealed that body image and appetite 
improved in the MA group but not the placebo group. Adverse event fre- 
quency and type were similar in both groups, but Cortisol and testosterone 
(in men) levels decreased substantially in the MA group. CONCLU- 
SIONS: We conclude that MA safely increased appetite and body weight, 
stimulated ventilalion. and impro\ed body image in underweight COPD 
palieiils. hut did iioi iniprove respiratory muscle function or exercise tol- 

Isokinetic Muscle Function in COPD — Haccoun C. Smountas AA, 
Gibbons WJ, Bourbeau J, Lands LC. Chest 2002 Apr:l2l(4):l079-I084. 

AIM: Exercise limilation in patients with COPD has been attributed to 
impaired ventilation and reduced skeletal muscle function. We have pre- 
viously used a combination of FEV| and leg muscle function (work 
achieved during a 30-s isokinetic sprint test) to predict progressive exer- 
cise capacity. However, the 30-s test may not be well tolerated in patients 
with advanced lung disease. We studied the relationship between pro- 
gressive exercise capacity, FEV|. and isokinetic work in patients with 
COPD and in healthy control subjects to assess whether the work accom- 
plished at time intervals of < 30 s could also be used to predict progres- 
sive maximal exercise capacity (Wmax). METHODS: Twenty-seven 
patients with COPD and 29 control subjects underwent anthropometric 
measures, spirometry, progressive cycle ergcmielry. and 30-s isokinetic 
cycling. RESULTS: There was no significant difference for weight, 
height, or body mass index between the groups. The COPD group was 
slightly older and had a significantly lower FEV| than control subjects. 
They also had a lower Wmax (56 ± 28.3 W vs 14 1 .9 ± 46.7 W) and isoki- 
netic work accomplished over 10 s (WIO). over 15 s (WI5). over 20 s 
(W20). over 25 s (W25). and over 30 s (W30). Wmax correlated in both 
patients with COPD and in control subjects with WIO. WI5. W20. W25, 
W30, and FEV|. Combining FEV| and isokinetic work (WIO, WIS. 
W20, W25, or W30) in a two-factor model to predict Wmax, the coeffi- 
cients of determination (r-) for patients with COPD were 0,57, 0.57. 0.58, 
0.59. and 0.58. and for control subjects were 0.69. 0.69. 0.71. 0.71. and 
0.73. respectively. Wmax correlated with weight only in control subjects. 
CONCLUSIONS: Both ventilatory function and leg muscle function con- 
tribute to exercise limitation, and a 20-s isokinetic test can be utilized to 
assess leg function in patients wiih COPD, 

.\n Evaluatiim of Two .Approaches to F.xcrcise Conditioning in Pul- 
monary Rehabilitation — Normandin E.-\. McCusker C. Connors M. 
Vale F, Gerardi D, ZuWallack RL. Chest 2002 Apr: 12 Il4 1:1085-1091. 

STUDY OBJECTIVES: To compare the effectiveness of two forms of 
exercise training in pulmonary rehabilitation. DESIGN: A prospective, 
randomized, unblinded. 8-week trial. SETTING: A hospital-based outpa- 
tient pulmonary rehabilitation program. PATIENTS: Forty patients (20 
patients In each group) with COPD who were referred for pulmonary 
rehabilitation. INTERVENTIONS: We compared the short-term effec- 
tiveness of a high-intensit\. lower-extremity endurance program with a 
low-intensity, mullicompoiicnl calisthenics program for the rehabilitation 
of patients with COPD. The high-intensity group trained predominately 
on the stationary bicycle and treadmill, with a goal of exercising at > 80% 
of maximal level determined from incremental testing for 30 min per ses- 
sion. The low-intensity group performed predominately classroom exer- 
cises for approximately 30 min per session. For both groups, twice- 
weekly sessions were held for 8 weeks. The primary outcome measure 
was health status, measured using the Chronic Respiratory Disease Ques- 
tionnaire. Other outcomes included peak oxygen consumption on incre- 
mental treadmill exercise testing, exertional dyspnea, treadmill 
endurance time, the number of sit-to-stand repetitions and arm lifts in I 
min, overall dyspnea, and questionnaire-rated lunclional status. MEA- 


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SUREMENTS AND RESULTS: Both groups showed signiricam postre- 
hiibiMiaiion improvement in exercise variables, exertional and overall 
dyspnea, functional perfoniiance, and health status. Patients in the high- 
intensity group showed greater increases in treadmill endurance and 
greater reductions in exertional dyspnea, whereas those in the low-inten- 
sity group showed greater increases in arm-endurance testing. Both 
groups had similar improvements in overall dyspnea, functional perfor- 
mance, and health status. CONCLUSIONS: Despite differences in exer- 
cise performance, both high-intensity, lower-extremity endurance train- 
ing and low-intensity calisthenics led to similar short-term improvements 
in questionnaire-rated dyspnea, functional performance, and health sta- 

Power of Outcome Measurements to Detect Clinically Significant 
Changes In Pulmonary Rehabilitation of Patients with COPD — de 

Torres JP, Pinto-Plata V, Ingenito E, Bagley P. Gray A, Berger R. Celli 
B. Chest 2002 Apr; 12 1(4): 1092- 1098. 

STUDY OBJECTIVES; Several validated instruments are used to mea- 
sure outcomes, such as exercise performance, dyspnea, and health-related 
quality of life after pulmonary rehabilitation (PR) in patients with COPD. 
However, no study has simultaneously compared the responsiveness of 
the most frequently used outcome measurements after PR. We designed 
this study to investigate the capacity of several of the most frequently 
used outcome measurements to detect changes after PR in a population of 

patients with severe COPD who qualified for lung volume reduction 
.^7 patients with severe COPD (FEV| < 40%) before and after 6 to 8 
weeks of outpatient PR. The following frequently used tools were evalu- 
ated: the 6-min walk distance (6MWD); functional dyspnea with the 
Medical Research Council (MRC) scale; baseline and transitional dysp- 
nea index (BDI/TDI); resting and 6MWD visual analog scale (VAS): 
quality of life with a generic tool (the Short Form-36 |SF-36)); and two 
disease-specific tools, the Chronic Respiratory Disease Questionnaire 
(CRQ) and the St. George's Respiratory Questionnaire (SGRQ). 
RESULTS: After PR, mean ± SD 6MWD increased in 33 of 37 patients 
(89%), from 28.^ ± 97 to 343 ± 92 m (p = 0.009). Improvements were 
seen also in the MRC scale in 23 of 37 patients (62%; from 2.27 ± 0.8 to 
1 .86 ± 0.6; p = 0.01 ); in CRQ dyspnea in 2."^ of 37 patients (67%; from 
3.2.') ± 0.9 to 3.90 ± 1.4; p = 0.02); in CRQ mastery in 22 of 37 patients 
(60%; from 4.37 + 1 .4 to 5. 14 ± 1 .3; p = 0.01 ); and in BDIATDI functional 
in 24 of 37 patients (64%; from 1.4 ± 0.8 to 0.7 ± 1.1; p = 0.002). There 
were smaller improvements in the SGRQ in 18 of 37 patients (48%) and 
in the SF-36 in 1 9 of 37 patients (51%), but they were not statistically sig- 
nificant. There were good correlations between the dyspnea components 
of all the tools. The 6MWD change did not correlate with the changes in 
the other outcomes. Clinically significant changes in the values for those 
outcome tools were detected in > 50% of patients for the BDI/TDI, 29% 
of patients for the MRC scale, in 37% of patients for the 6MWD, in 48% 
of patients for the VAS at peak exercise, in > 50% of patients for the 


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CRQ. ami in 40', ol palierils li>r the SGRQ, CONCLUSIONS: We con- 
elude that the VAS peak exercise. BDl/TDl. and CRQ adequately reflect 
the benellcial effects of PR. The 6MWD c\aluatcs a unique domain not 
related to quality of life. Due to their simplicity and sensitivity, VAS at 
peak e.vercise. 6MWD, and CRQ ma\ be the best practical tools to evalu- 
ate responsiveness to PR. 

Stair Climbing Test Predicts Cardiopulmonary Complications After 
Lung Resection — Brunelli A. Al Refai M. Monleverde M. Borri A, 
Salali M. Fianchnii A. Chest 2002 Apr;l2ll4l:l 106-1 1 10. 

STUDY OBJECTIVE: To evaluate the capability of the stair climbing 
test to predict cardiopulmonary complications after lung resection for 
lung cancer. DESIGN: A prospective cohort of candidates for lung resec- 
tion. Spironietric assessment and the stair climbing test were performed 
the da\ before operation. Uni\ariate and multivariate analyses were per- 
formed to identify predictors of postoperative complications. SETTING: 
Tertiary referral center. P.-XTIENTS: A consecutive series of 160 candi- 
dates for lung resection with lung carcinoma from January 2000 through 
March 2001. RESULTS: At univariate analysis, the patients with compli- 
cations were significantly older (p = 0.02). had a significantly lower 
FEVi percentage (p = 0.007) and predicted postoperative FEV| percent- 
age lp = 0.01 ), had a greater incidence of a concomitant cardiac disease (p 
= 0.02). climbed a lower altitude at the stair climbing test (p < 0.0001 ). 
and had a lower calculated ma.ximum oxygen consumption (0:„,a^) |p = 

0.0-^1 and predicted postoperative Ojm.iv IP = 0()06) compared I'- '''^ 
patients without complications. At multivariate analysis, the altituMe 
reached at the stair climbing test remained the only significant indepen 
dent predictor of complications. CONCLUSIONS: The stair climbing test 
is a safe and economical exercise test, and it was the best predictor of . ar 
diopulmonaiy complications after lung resection 

Effects of an Intensive 4-\\eek .Siminier (amp on Cystic Fihrosi*; 
Pulmonary Function, Kxerclse Tolerance, and Notrillon Bl:iu H, 

Mussaffi-Geoig) H. link G. Kayc C", S/einberg A. Spii/or SA. Yah-iv J. 
Chest 2002 Apr:l21(4): II 17-1 122. 

STUDY OBJECTIVES: Cystic fibrosis (CF) patients prefer exercise fo 
most other forms of therapy, although objective improvement rerniins: 
controversial. Israeli CF patients have attended a summer program in 
Switzerland for many years with subjective improvement. However. CF 
camps worldwide have been cancelled recently, due to fears of -.T'iss 
infection with resistant organisms. Therefore, we evaluated the effect of 
attending the camp on pulmonary function, exercise tolerance, and nutri- 
tional state in CF patients. DESIGN: Weight, resting pulmonary function, 
incremental exercise test results, and sputum culture findings were 
assessed before and after a 4-week intensive summer camp. SETTING 
Davos. Switzerland (altitude, 1,500 m). PATIENTS: Thirteen Israeli CF 
patients (seven women and six men) with an age range of 9 to 2f> years 
who had mild-to-moderate lung disease. No patients had Riirklu<hhi' 


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Respir.atory Care . September 2002 Vol 47 No 9 



ceiHuia delected in then sputum. INTERVEN'IIONS: The program 
included a high-calorie diet, chest physiotherapy, daily mountain climb- 
ing, and indoor activities. Arterial oxygen saturation (Sao,) was main- 
tained at > 88'7r during exertion. RESULTS: Exercise tolerance improved 
significantly. The peak work capacity increased by 12.7%. the maximal 
oxygen uptake increased by 1()9(. and minute ventilation increased by 
18..'i'/( (p < 0.0005). Of the calculated parameters, the anaerobic threshold 
improved by 17Vr. Ventilation was always the lintiting factor during 
exercise, although it improxed. There « as no significant change in resting 
lung function and pulse or in Sjo, decline at maximal exercise. The mean 
weight gain was I kg. No patient acquired B cepacia. CONCLUSIONS: 
An intensive summer camp improved exercise tolerance and nutrition in 
CF patients. This may explain improved patient well-being despite 
unchanged values for resting lung function. The reinstitulion of summer 
camps, with special care to avoid cross-infection, should be considered. 

Evaluation of a Cough-Specific Quality-of-Life Questionnaire — 

French CT. Irwin RS. Fletcher KE, Adams TM. Chest 2002 

STUDY OBJECTIVE: To psychometrically evaluate a cough-specific 
quality-of-life questionnaire (CQLQ) in adults. DESIGN: Prospective 
evaluation of CQLQ using three different cohorts of adult subjects with 
cough. SETTING: Academic tertiary-care ambulatory medical facilities. 
PARTICIPANTS: One hundred fifty-four subjects complaining of 
chronic cough. .10 of acute cough, and .11 smokers with cough. INTER- 
VENTIONS: Self-adniinistralion of the CQLQ in acute coughers. smok- 
ers, and chronic coughers before and after therapy. MEASUREMENTS: 
Psychometric analyses including factor analysis (FA), and assessments of 
reliability and validity. RESULTS: Acute and chronic cough data were 
subjected to FA, and the Cronbach alpha and interitem correlations were 
computed. FA of chronic and acute cough data (n = 184) revealed six sub- 
scales. The Cronbach alpha for the total CQLQ was 0.92. and it was 0.62 
10 0.86 (mean. 0.76) for the six subscales. Interitem correlations for the 
total CQLQ ranged from -0.06 to 0.72. with a mean of 0.28. Test-retest 
reliability in 52 chronic coughers demonstrated nonsignificant changes 
with readministration of the questionnaire, and the intraclass correlation 
for total CQLQ was 0.89. and for the subscales the range was 0.75 to 
0.93. Analysis of variance followed by tests of contrasts among all possi- 
ble pairings of chronic coughers. acute coughers. and smokers showed 
significant differences (p < 0.001) among the groups. Posttreatment cure 
scores were significantly lower (p < or = 0.001 ) than pretreatment scores 
in 24 chronic coughers. CONCLUSIONS: The 28-item CQLQ has 
dimensionality that is consistent with a cough-specific quality-of-life 
instrument. It is a valid and reliable method by w hich to assess the impact 
of cough on the quality of life of chronic and acute coughers. and the effi- 
cacy of cough therapies in chronic coughers. 

Noninvasive Positive-Pressure Ventilation >s. Conventional Oxygen 
Supplementation in Hypoxemic Patients Undergoing Diagnostic 

ItnpMchiiscopy — Antoiielli M. Conti G. Rocco M, Arcangcli .A. Cava- 
here F. Proietti R. Mcduri GU. Chest 2002 Apr;l21(4):l 149-1154. 

OBJECTIVE: We have reported previously on the use of noninvasive 
positive-pressure ventilation (NPPV) to assist spontaneous breathing in 
high-risk hypoxemic patients (i.e.. Pao,/fraction of inspired oxygen (FiotI 
ratio, < 100) who are undergoing diagnostic fiberoptic bronchoscopy 
(FOB). The efficacy of this intervention in patients with less severe forms 
of hypoxemia (i.e.. Pao/F|o, ratio. < 200) is unknown. PATIENTS AND 
METHODS: Twenty-six patients with P.i(),/Fio, ratios < 200 who 
required bronchoscopic B.M. for suspected nosocomial pneumonia were 
entered into the study. Thirteen patients were randomized during FOB to 
receive NPPV. and 13 patients were randomized to receive conventional 
oxygen supplementation by Venturi mask. The primary end points were 
changes in the PaoVFlo, ratio during FOB and vv itlnn 60 niin of terminat- 

ing the procedure. RESULTS AND OUTCOME: At study entry, the two 
groups were similar in terms of age, simplified acute physiologic score II 
values, and cardiorespiratory parameters. During FOB. the mean (± SD) 
Pao7Fio, ratio increased by 82'/r in the NPPV group (261 ± 100 vs 139 ± 
38; p < 0.001 ) and decreased by lO'/r in the conventional oxygen supple- 
mentation group (155 ± 24 to 139 ± 38; p = 0.23). Sixty minutes after 
undergoing FOB. the NPPV group had a higher mean PaO,/F|o, ratio ( 1 76 
± 62 vs 140 ± 38; p = 0.09), a lower mean heart rate (91 ±"l8 vs. 108 ± 15 
beats/min: p = 0.02), and no reduction in mean arterial pressure in com- 
parison to a 15'/f decrease from the baseline in the control group. One 
patient in the NPPV group and two patients in the control group required 
nonemergent intubation. Major bacterial isolates included Staphylococ- 
cus aureus (7 of 30 isolates: 23%) and Pseuclomonas aeruginosa (12 of 
30 isolates; 40%). CONCLUSION: In patients with severe hypoxemia. 
NPPV is superior to conventional oxygen supplementation in preventing 
gas-exchange deterioration during FOB with better hemodvnamic toler- 

Management of Pneumothorax After Percutaneous CT-Guided 
Lung Biopsy — Yamagami T. Nakamura T. lida S. Kato T. Nishimura T. 
Chest 2002 Apr; ! 2 1 ( 4 ): 1 1 59- 1 1 64. 

OBJECTIVES: To evaluate the efficacy of simple aspiration of air from 
the pleural space to prevent increased pneumothorax and to avoid chest 
tube placement in cases of pneumothorax following CT-guided lung 
biopsy. DESIGN: Observational. .MATERIALS AND METHODS: One 
hundred thirty-four consecutive percutaneous needle lung biopsies using 
real-time CT fluoroscopy guidance formed the basis of our study. All 
patients that demonstrated moderate or severe pneumothorax on post- 
biopsy chest CT images underwent percutaneous manual aspiration 
regardless of symptoms while on the CT scanner table. Correlation 
between the incidence of pneumothorax after biopsy and many factors 
(i.e., gender, age. number of pleural passes, presence of emphysema, 
lesion size, and lesion depth) were determined, and management of each 
case of biopsy-induced pneumothorax was reviewed. RESULTS: Post- 
biopsy pneumothorax occurred in 46 of 134 procedures (34.3% ). Twenty 
of the 46 patients were treated by manual aspiration, while 26 patients 
were simply observed. In 43 of the 46 pneumothoraces (93.5%), the 
pneumothorax resolved completely on follow-up chest radiographs with- 
out requiring tube placement. Only three patients (2.2% of the entire 
series; 6.5% of those who had pneumothorax develop) required chest 
tube placement. The risk of pneumothorax significantly increased with 
lesion size and depth. CONCLUSION: Results of our nonprospective. 
nonrandomized study suggest that percutaneous manual aspiration of 
biopsy-induced pneumothorax pertbrmed immediately after biopsy may 
prevent progressive pneumothorax and subsequent chest tube placement. 

A Multicenter Description of Intermediate-Care Patients: Compari- 
son with ICU Lo\v-Risl\ Monitor Patients — Junker C. Zimmerman JE. 
Alzola C. Draper EA. Wagner DP. Chest 2002 Apr; 1 2 1(4 ): 1 253- 1 26 1 . 

STUDY OBJECTIVES: To describe the characteristics and outcomes of 
patients admitted to intermediate-care areas (ICAs) and to compare them 
w ith those of ICU patients who receive monitoring only on day 1 and are 
at a low risk (i.e.. < 10%) for receiving subsequent active life-supporting 
therapy (i.e.. low-risk monitor patients). DESIGN: Nonrandomized, ret- 
rospective, cohort study. SETTING; Thirteen US teaching hospitals and 
19 nonteaching hospitals. PATIENTS: A consecutive sample of 8.971 
patients at 37 ICAs and 5.1 16 low-risk (i.e.. < 10% ) monitor patients at 
59 ICUs in 32 US hospitals. INTERVENTIONS: None. MEASURE- 
ME.NTS AND RESULTS: We recorded demographic and clinical char- 
acteristics, resource use. and outcomes for the IC.A and ICU low-risk 
monitor patients. Patient data and outcomes for this study were collected 
concurrently or retrospectively. IC.-^ and ICU low -risk monitor patients 
were similar in regard to gender, race, and frequency of coinorbitities. but 


Respir.'XTOry Carl . September 2002 Vol 47 No 9 



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ICA piitients were significantly (p < 0.(K)1 ) older, had fewer physiologic 
ahnorinalilics (mean acute physiology score. 16.7 vs 19.8, respectively), 
anil were more frei.|uently admitted due to nonoperative diagnoses. The 
mean length of slay lor \C.\ patients was significantly longer (3.9 days) 
than for ICIJ low -risk inomtor patients (2.6 days; p< 0.001 ). The hospital 
mortality rate was significantly higher for ICA palients (.3.1'* I compared 
to ICU low-risk monitor patients (2.3';^; p = 0.002). CONCLUSIONS: 
The clinical features of ICA patients are similar, but not identical to, 
those of le,ss severely ill ICU monitor patients. Comparisons of hospital 
death rates and lengths of stay for these patients should be adjusted for 
characteristics that previously have been shown to influence these out- 

Pulmonary Dysfunction .After Cardiac .Surgery — Ng CS, Wan S, Yim 

AP. Arifi AA,, Chcsi :()(i: Apr; i 2 l(4l: 1269-1277. 

Postoperative lung injury is one of the most frequent complications of 
cardiac surgery that impacts significantly on health-care expenditures and 
largely has been believed to result from the use of cardiopulmonary 
bypass (CPB). However, recent comparative studies between conven- 
tional and off-pump coronary artery bypass grafting have indicated that 
CPB itself may not he ihe major contributor to the de\elopment of post- 
operative pulmonary dysfunction. In our study, we review the associated 
physiologic, biochemical, and histologic changes, with particular refer- 
ence to the current understanding of underlying mechanisms. Intraopera- 
tive modifications aiming at limiting lung injury are discussed. The 
potential benefits of maintaining ventilation and pulmonary artery perfu- 
sion during CPB w arrant further investigation. 

The Design of Randomized Clinical Trials in Critically 111 Patients — 

Hebert PC. Cook DJ. Wells G. Marshall J. Chest 2002 Apr;121(4):1290- 

There are a number of difficulties in the conduct of randomized trials in 
the critically ill. These include difficulties in the definition of diseases 
and syndromes, a heterogenous population of patients undergoing a vari- 
ety of therapeutic interventions, and outcomes that may not be able to dis- 
criminate between beneficial and risky therapies. Following a brief 
description of different randomized clinical trials (RCTsl and design 
philosophies, we outline the elfects of different design choices in the 
complex critical care environment. Once the study topic has been deter- 
mined to be relevant and important, then the potential investigator must 
establish whether efficacy or effectiveness will be the focus of the RCT. 
If an effectiveness design philosophy is chosen, then broad representation 
of study sites, liberal eligibility criteria, easily implemented intervention 
study protocols, and patient-centered outcomes should be chosen. The 
potential investigator w ishing to establish efficacy will conduct the study 
in the centers of excellence and adopt stringent eligibility criteria, rigor- 
ous study protocols, and opt for outcomes that will he sensitive to change. 
In conclusion, we describe some of the major challenges and possible 
solulions to help a potential investigator through the myriad of difficulties 
111 initiating an RCT in a complex environment. 

.\n Evaluation of Ihe Quality and Contents of Asthma Education on 
the World Wide Web— Croft DR. Peterson MW. Chest 2002 

STUDY OBJECTIVES: To measure the accessibility and quality of cur- 
rently available asthma education World Wide Web sites using the fol- 
lowing criteria: accessibility by readability, language, and download 
time; information quality based on inclusion of core educational concepts 
and compliance with Health On the Net (HON) principles; and utilization 
of innovative technology. DESIGN; Objective evaluation of 145 Web 
sites. MEASUREMENTS AND RESLILTS: Four search engines or 
directories (Yahoo, HON, Alta Vista, and Healthfinder) were searched 

for "asthma, patient information." A maximum of 50 Web sites from each 
search engine or directory was evaluated. Only 90 of the 145 Web sites 
actually contained asthma educational material. The mean (± SDl time 
necessary to open each Web site on a 28.S00-bits-per-second modem was 
33.6 ( ± 36.6) s. The mean number of graphics on the Web sites was 24.6 
( ± M).2) files per page. The educational material required a mean reading 
level beyond the 1 0th grade. Only nine Web sites contained multilingual 
asthma education material. The mean number of HON principles with 
which the Web sites conformed was 6.3 ( ± 1.0) of 8 principles; 14 Web 
sites conformed to all the HON criteria. The average Web site contained 
4.9 (± 2.5) of 8 core asthma educational concepts, and only 20 Web sites 
contained all 8 educational concepts. Very few Web sites utilized innova- 
tive educational technology. CONCLUSIONS: While patient asthma 
education Web sites are common, asthma educational material contains 
many accessibility barriers, is highly variable in quality and content, and 
takes little innovative use of technology. Patient educational material cur- 
rently available on the World Wide Web fails to meet the information 
needs of patients. 

The Increase in Allergic Respiratory Diseases: Survival of the 

Fittest?— Varner AE. Chest 2002 Apr; 1 2 1 ( 4 1: 1 .W8- 1 3 1 6. 

The pre\alence of allergic respiratory diseases, asthma and allergic 
rhinoconjunctivitis. has increased since the advent of industrialization. 
The inverse relationship between the number of infections early in life 
and atopy has been interpreted as the "hygiene hypothesis." That is, many 
infections early in life promote the development of T helper type 1 
cytokines, while fewer infections early in life favor the development of T 
helper type 2 (Th2) cytokines and atopy. An alternate interpretation of the 
same data, that atopy is protective against infections early in life, is rarely 
considered. With epidemiologic, historical, and immunologic data. I sug- 
gest that human evolution has favored individuals with an atopic predis- 
position. Th2 immune responses promote parity, and ensure successful 
pregnancy and term birth; provide the infant protection against infections 
and the intlammation induced by common pathogens in the t~irst years of 
life until the immune system matures; and protect young adults exposed 
to viral respiratory pathogens. These traits are of particular value with the 
advent of industrialization, especially so in the era prior to the develop- 
ment of antibiotics. This theory contradicts the assumption that there is no 
biological or evolutionary advantage for allergic disease to exist in 
humans and has significant implications for our current and future treat- 
ments of allergic diseases. 

Ethical .Assessment of Industry-Sponsored Clinical Trials: .\ Case 
Analysis— Miller FG, Shorr AF. Chest 2002 Apr; 121(41:1 337- 1 342. 

The rapid growth of clinical trials sponsored by the pharmaceutical indus- 
try and conducted by community physicians raises concerns about the 
scientific quality of this research and the adequacy of protections for 
research participants. In this article, we present an in-depth ethical analy- 
sis of a recent industry-sponsored placebo-controlled study for treatment 
of asthma. The ethical analysis uses a proposed ethical framework for 
evaluating clinical research focusing on seven ethical requirements: (1) 
scientific value, (2) scientific validity, (3) fair subject selection, (4) favor- 
able risk/benefit ratio, (5) independent review, (6) informed consent, and 
(7) respect for enrolled subjects. 

Management of .Acute Hypoxemia During Flexible Bronchoscopy 
with Insertion of a Nasopharyngeal Tube in Lung Transplant Recipi- 
ents— ('hhajcd I'N. Aboyoiin C. Malouf M.-\. Hopkins PM. Phi .\1. Grun- 
stein RR. CiUinMlle AR Chest 2002 Apr;l21(4l:I.V50-13.54. 

STUDY OBJECTIVES: To assess the utility of nasopharyngeal tube 
insertion in the management of hypoxemia during flexible bronchoscopy 
(FB) in lung transplant recipients, and to determine the incidence and risk 





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factors of upper-airway obstruction (UA01 leading to significant hypox- 
emia during KB. SETTING: Heart-lung transplant unit of a university 
hospital. PATIENTS AND METHODS: Ninety-six lung transplant recip- 
ients (47 men and 49 women; mean ± SD age, 41.4 ± 13.1 years) under- 
went 714 FB procedures from January 1997 to May 2000. INTERVEN- 
TION: A fall in oxygen saturation (< 90%) in patients receiving 6 L/min 
of oxygen via nasal prongs was treated with insertion of a nasopharyngeal 
tube, continued oxygen supplementation, and withdrawal of the broncho- 
scope to the trachea. If oxygen desaturation persisted at < 90% despite 
additional oxygen administration via a 7F catheter placed either just 
above the larynx or in the proximal trachea, the bronchoscope was with- 
drawn, reversal of sedation was administered, and bag and mask ventila- 
tion was instituted until satisfactory spontaneous ventilation was 
achieved. RESULTS: Forty-six patients (47.9%) were treated with 
nasopharyngeal tube insertion on 102 occasions at a mean duration of 168 
+ 178 days after lung transplantation. In 90 of 102 procedures (88.2%), 
significant hypoxemia due to UAO was successfully treated with 
nasopharyngeal tube insertion. The mean oxygen saturation after 
nasopharyngeal tube insertion was 97 ± 3%, Male gender, increase in 
body mass index after lung transplantation, and presence of obstructive 
sleep apnea were significant factors associated with the need for nasopha- 
ryngeal tube insertion during FB in lung tfansplant recipients. CONCLU- 
SIONS: Significant oxygen desaturation during FB in lung transplant 
recipients is mainly due to UAO. Insertion of a nasopharyngeal tube is a 
novel and a highly effective approach to the management of acute hypox- 
emia during FB. 

A Qualitative Study of Action Plans for Asthma — Douglass J, Aroni 
R. Goeman D. Stewart K, Sawyer S, Thien F, Abramson M. BMJ 2002 
Apr 27:324(7344): 1003-1005. 

OBJECTIVES: To investigate the perspectives of patients with asthma on 
the use of an action plan and the implementation of this plan during an 
asthma attack that culminated in a visit to an emergency department. 
DESIGN: Qualitative study. SETTING: Tertiary teaching hospital, sub- 
urban hospital, and rural hospital. PARTICIPANTS: 62 patients aged 18 
to 69 years who presented to an emergency department with asthma over 
a two month period. RESULTS: 29 participants described having action 
plans given to them by their doctors. Most patients with action plans rein- 
terpreted their plan from the perspective of their own experiences with 
asthma. 33 patients did not have an action plan, the most common reason 
being that they had not been given one by their doctor. Some occupa- 
tional groups were significantly less likely to have been given an action 
plan by their doctor than others. Most patients with an action plan found 
them useful for management of their asthma. CONCLUSIONS: Action 
plans were viewed positively by patients. Participants modified their pre- 
scribed plan according to their experience of asthma. To facilitate the 
implementation of a prescribed action plan, doctors need to acknowledge 
and include the patient's personal experience of their disease. 

Mechanical Properties of the Lung and Upper Airways in Patients 
with Sleep-Disordered Breathing — Bijaoui EL. Champagne V. Bacon- 
nier PF, Kimoff RJ, Bates JH. Am J Respir Crit Care Med 2002 Apr 

We studied the changes in lung and upper airway mechanics in adult 
human subjects with obstructive sleep apnea/hypopnea syndrome 
(OSAHS) during wakefulness, sleep, and at arousal from sleep. We used 
two numerical methods that we have previously developed specifically 
for dealing with inspiratory tlow limitation during sleep: the modified 
Mead-Whittenberger method, and information-weighted histograms 
obtained using recursive least squares. Full polysomnography including 
esophageal pressure and airflow measurements was performed in seven 
men with OSAHS (respiratory disturbance index: 55.8 ± 23.2 events/h). 
Pharyngeal pressure was recorded in four of the subjects to partition lung 

mechanics into its upper airway and lower lung components. Both tech- 
niques showed that total lung resistance and elastancc increased signifi- 
cantly (p < 0.(J5) during obstructed breathing and that this increase was 
reversed at the end of the obstruction. The partitioning of mechanics 
showed that upper airway collapse was primarily responsible for the 
increase in lung resistance. Our results suggest that OSAHS may lead to 
transient abnormalities in the recruitment of lung units and the gas 
exchanging capacity of the lungs. 

Pressure-Volume Curves in Acute Respiratory Distress Syndrome: 
Clinical Demonstration of the Influence of Expiratory Flow Limita- 
tion on the Initial Slope — Vieillard-Baron A, Prin S, Schmitt JM, 
Augarde R, Page B, Beauchet A, Jardin F. Am J Respir Crit Care Med 
2002 Apr I5;I65(8):1 107-1 112. 

The presence of an initial segment with a low compliance on the static 
pressure-volume (PV) curve in patients with acute respiratory distress 
syndrome (ARDS) indicates that some lung compartments do not initially 
receive insufflated gas. We tested the hypothesis that an uneven distribu- 
tion of time constants, producing a "slow compartment," was in part 
responsible for the change in compliance between the initial and the inter- 
mediate segment of the PV curve. In 16 patients with ARDS submitted to 
mechanical ventilation in volume-controlled mode with a supportive res- 
piratory rate of 15 breaths/minute, we constructed the static PV curve on 
the first day of respiratory support and determined the intrinsic positive 
end-expiratory pressure (PEEPi4) during a prolonged end-expiratory 
pause (4 seconds). We also measured the volume of a "slow compart- 
ment" during a prolonged expiration (> 6 seconds), and determined an 
external PEEP (PEEPe) suppressing PEEPi4. Among the 16 patients 
studied, 1 1 exhibited a low inflection point, associated with a "slow com- 
panment" of 172 + 83 mL, responsible for a PEEPi4 of 3 ± 2 cm H:0. 
Conversely, the five remaining patients had a linear PV curve, associated 
with a minimal "slow compartment" of 28 ± 10 mL, responsible for a 
negligible PEEPi4. We observed that individual slopes of the initial seg- 
ment of the PV curve were inversely and significantly correlated w ith the 
proportion of the "slow compartment" (r = -0.85). We concluded that the 
shape of the inspiratory PV curve in ARDS might be dependent on the 
presence of a "slow compartment," and demonstrated that a low external 
PEEP appeared sufficient to achieve a substantial mechanical improve- 
ment in clinical practice. 

One-Night Mandibular Advancement Titration for Obstructive 
Sleep Apnea Syndrome: A Pilot Study — Petelle B, Vincent G, Gag- 
nadoux F, Rakotonanahary D. Meyer B, Fleury B. Am J Respir Crit Care 
Med 2002 Apr 15;165(8):I150-1I53. 

The effect of a dental appliance (DA) is usually evaluated in a single 
mandibular position reached after several weeks and corresponding to 
either improvement of symptoms or intolerance to any further advance- 
ment. The purpose of this study was to test the feasibility of one-night 
evaluation of the efficacy of a DA. The study population consisted of 
seven patients (six men) with obstructive sleep apnea syndrome (66.9 ± 
32.4 apneas and/or hypopneas per hour). Patients underwent two con- 
secutive polysomnographies; first with a temporary DA (two arches 
connected by a hydraulic system) progressively adjusted during the 
night to correct sleep disordered breathing and second with a permanent 
DA (two arches connected by Herbst attachments) set to the effective 
degree of advancement during the titration night. All patients com- 
pleted the protocol. The mean mandibular advancement reached during 
the titration night was 12.6 ± 2.7 mm. Arousal was never observed dur- 
ing or for 60 seconds following advancement. The apnea-hypopnea 
index (AHI) was significantly reduced from 66.9 ± 32.4 to 26.1 ± 20.7 
per hour during the titration night from the diagnostic night (p < 0,01). 
During the second night, the AHI was 19.6 ± 20.2 per hour and was less 
than 20 per hour in 7 1 ,4% of patients and less than 1 per hour in 42.9% 


Respiratory Care . September 2002 Vol 47 No 9 

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Clinical Findings and Lung Pathology in Children with Cystic Fibro- 
ses — Hamutcu R. Rowland JM, Horn MV, Kaminsky C, MacLaughlin 
EF, Starnes VA. Woo MS. Am J Respir Grit Care Med 2002 Apr 
l5:lft?(S):l 172-1 175. 

Cystic fibrosis pulmonary disease is assessed by pulmonary function 
tests, arterial hlood gases, and chest x-rays, but the correlation with lung 
pathology is unknown. We reviewed the clinical findings and lung 
pathology of 21 cystic fibrosis patients who had lung transplant. Pul- 
monary function tests. Brasfield scores, arterial blood gases, and age 
were correlated with lung pathology. All patients had severe Brasfield 
scores (9.0 ± 3.2), airways obstruction (FEVj 25.6 + 5.6% predicted, 
FEF25.75.J 11.0 ± 4.5% predicted), and hyperinflation (residual volume 
[RV] 341.8 ±75.8% predicted). All patients were hypoxemic (Pq, 64.2 ± 
8,2 mm Hg), and 5 of 21 (24%) were hypercapneic (Pcoj > 50 mm Hg). 
Pulmonary function tests and Brasfield scores were within a narrow 
range, and did not allow correlation with lung pathology. Small airway 
density (airways < 2 mm/cm-) decreased with increasing age. There were 
no differences in small airways inflammation and fibrous narrowing 
between the hypercapneic and nonhypercapneic patients, but the percent 
of smallest airways (airways < 0.35 mm) was significantly lower in the 
hypercapneic group. We conclude that there is significant correlation 
between airway pathology and increased age and CO2 retention. We 
speculate that decreased small airway density in older patients and the 
decreased proportion of smallest airways in hypercapneic patients is 
caused by increased dilatation of small airways. 

Pathogenesis of High-Altitude Pulmonary Edema: Inflammation Is 

Not an P^tiologic Factor — Swenson ER. Maggiorini M. Mongovin S, 
Gibhs JS. Greve 1, Mairbaurl H, Bartsch P. JAMA 2002 May 

CONTEXT: The pathogenesis of high-altitude pulmonary edema 
(HAPE) is considered an altered permeability of the alveolar-capillary 
barrier secondary to intense pulmonary vasoconstriction and high capil- 
lary pressure, but previous bronchoalveolar lavage (BAD findings in 
well-established HAPE are also consistent with inflammatory etiologic 
characteristics. OBJECTIVES: To determine whether inflammation is a 
primary event in HAPE and to define the temporal sequence of events in 
July through August 1999 of 10 subjects with susceptibility to HAPE and 
6 subjects resistant to HAPE, all of whom are nonprofessional alpinists 
with previous mountaineering experience above 3000 m. MAIN OUT- 
COME MEASURES: Pulmonary artery pressure measurements and BAL 
findings at low altitude (490 m) and shortly before or at the onset of 
HAPE at an altitude of 4559 m. RESULTS: Subjects who were HAPE 
susceptible had higher mean (SD) pulmonary artery systolic blood pres- 
sures at 4559 m compared with HAPE-resistanl subjects (66 vs 37 mm 
Hg; p = 0.004). Despite development of HAPE in the majority of HAPE- 
susceplible subjects, there were no differences in BAL fluid total leuko- 
cyte counts between resistant and susceptible subjects or between counts 
taken at low and high altitudes. Subjects who developed HAPE had BAL 
fluid with high concentrations of plasma-derived proteins and erythro- 
cytes, but there was no increase in plasma concentrations of surfactant 
protein A and Clara cell protein. The chest radiograph score was 12.7 for 
the 3 HAPE-susceptible subjects who developed HAPE before BAL was 
performed; they were lavaged within 3 to 5 hours. The remainder of the 
HAPE-susceptible group was lavaged before edema was apparent on 
radiographs. However, 6 subjects from the HAPE-susceptible group who 
developed HAPE on the following day had a score on bronchoscopy of 
1.5, which increased to 4.6, reflective of mild pulmonary edema. In 
HAPE cases, there were no elevations in a number of proinflammatory 

cytokines and eicosanoid and nitric oxide metabolites. CONCLUSIONS: 
Early HAPE is characterized by high pulmonary artery pressures that lead 
to a protein-rich and mildly hemorrhagic edema, with normal levels of 
leukocytes, cytokines, and eicosanoids. HAPE is a form of hydrostatic 
pulmonary edema with altered alveolar-capillary permeability. 

Anthrax As a Biological Weapon, 2002: Updated Recommendations 
for Management — Inglesby TV. O'Toole T. Henderson DA. Bartlett JG. 
Ascher MS. Eitzen E, et al. Working Group on Civilian Biodefense. 

JAMA 2002 May l;287(17):2236-2252. 

OBJECTIVE: To review and update consensus-based recommendations 
for medical and public health professionals following a Bacillus 
anlhracis attack against a civilian population. PARTICIPANTS: The 
working group included 23 experts from academic medical centers, 
research organizations, and governmental, military, public health, and 
emergency management institutions and agencies. EVIDENCE: MED- 
LINE databases were searched from January 1966 to January 2002, using 
the Medical Subject Headings anthrax. Bacillus anlhracis. biological 
weapon, biological terrorism, biological warfare, and biowarfare. Refer- 
ence review identified work published before 1966. Participants identi- 
fied unpublished sources. CONSENSUS PROCESS: The first draft syn- 
thesized the gathered information. Written comments were incorporated 
into subsequent drafts. The final statement incorporated all relevant evi- 
dence from the search along with consensus recommendations. CON- 
CLUSIONS; Specific recommendations include diagnosis of anthrax 
infection, indications for vaccination, therapy, postexposure prophylaxis, 
decontamination of the environment, and suggested research. This 
revised consensus statement presents new information based on the anal- 
ysis of the anthrax attacks of 2001, including developments in the investi- 
gation of the anthrax attacks of 2001; important symptoms, signs, and 
laboratory studies; new diagnostic clues that may help future recognition 
of this disease; current anthrax vaccine information; updated antibiotic 
therapeutic considerations; and judgments about environmental surveil- 
lance and decontamination. 

Risk Factors for Severe Respiratory Syncytial Virus Infection in 

Infants— Aujard Y. Fauroux B. Respir Med 2002 Apr;96 SuppI B:S9- 

Severe respiratory syncytial virus (RSV) disease is associated with unac- 
ceptable morbidity and mortality in children, especially in young chil- 
dren. Underlying conditions including prematurity with or without bron- 
chopulmonary dysplasia, congenital heart disease, immunosuppression or 
another underlying respiratory condition, such as cystic fibrosis, increase 
the risk of contracting and developing severe RSV disease. Environmen- 
tal factors such as crowding, day-care attendance, and exposure to pas- 
sive smoke can increase the risk of severe RSV disease. Children with 
severe RSV disease often require intensified medical care, including hos- 
pitalization, which places a burden on the child, the family, and the health 
care system. There are currently no effective curative treatments for 
severe RSV disease. Preventive measures, such as infection control and 
prophylaxis, appear to be the best options in the management of RSV dis- 
ease in these high-risk patients. 

An Update on Respiratory Syncytial Virus Epidemiology: A Devel- 
oped Country Perspective — Law BJ. Carbonell-Estrany .X. Simoes EA. 
Respir Med 2002 Apr;96 Suppl B:S1-S7. 

Respiratory syncytial virus (RSV) is a leading cause of lower respiratory 
tract infections in infants and young children worldwide, and an impor- 
tant cause of morbidity, hospitalization, and mortality. The infections 
caused by RSV are seasonal, peaking predictably in the winter months in 
temperate climates, and in the hottest months and the rainy season in trop- 
ical climates. The mvolvement of the lower respiratory tract, manifest 


Respiratory Care . September 2002 Vol 47 No 9 




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clinically as hrimcliiiililis or pneumonia, is Ihe hallniaik of severe RSV 
disease. Other indicators ot severe disease include requirement lor. and 
duration of, hospitalization, supplemental oxygen, management in an 
intensive care setting, and mechanical ventilation. Host-related risk fac- 
tors for severe RSV disease include preterm birth, infection before 6 
months of age. chronic lung disease, and congenital heart disease. Envi- 
ronmental risk factors for severe RSV infection include poverty, crowd- 
ing, exposure to tobacco smoke, and malnutrition. Factors that increase 
frequency of the infection include young age. multiple gestation, family 
history of atopy, lack of parental education, household crowding, older 
school-age siblings, lack of breast feeding, day-care attendance, passive 
smoke exposure, and discharge from a neonatal intensive care unit 
between September and December. Recent studies in Europe, North 
America and Japan have evaluated the number of children affected as 
well as the medical resources necessary to care for these children. Contin- 
uing surveillance is the key to tracking the seasonality, risk factors, mor- 
bidity and mortality associated with RSV infection. Epidemiological 
studies are also the basis for development of appropriate local prevention 

Treatment of Latent Tuberculosis Infection in Contacts of New 
Tuberculosis Cases in the United States — Reichler MR, Reves R, Bur 
S. Ford J. Thompson V. Mangura B. et al. South Med J 2002 
.Apr:9.S( 4 ):4 14-420. 

B.ACKGROUND: Few data are available describing treatment comple- 
tion rates among recently infected contacts of tuberculosis (TB) cases, a 
group at high risk for development of active TB. METHODS: Health 
department records were reviewed for all contacts of 3&0 culture-positive 
pulmonary TB cases reported from five health departments in the United 
States in 1996. RESULTS: Of 2,267 contacts who completed screening, 
630 {28%) had newly documented positive skin tests {121 with skin test 
conversion). Treatment of latent TB infection was documented to have 
been recommended for 447 iliVc). Among these, treatment was docu- 
mented to be initiated for 39S (S99f). Of these. 203 (5['7r) were docu- 
mented to have completed a 6-month course of treatment, and 78 (20'X) 
received directly observed treatment. Treatment was recommended more 
often for contacts < 15 years of age. skin test converters, close contacts, 
and contacts of smear-positive cases. Treatment completion rates were 
higher for skin test converters. CONCLUSIONS: In this study, fewer 
than one third of all persons with newly documented positive skin tests 
detected during contact investigations were proven to have completed 
treatment. Achieving high rates of completion of therapy for latent TB 
infection in recently infected contacts of active cases of pulmonary TB is 
essential to maximize public health prevention efforts aimed at eliminat- 
ing TB. 

Effect of Driving Pressure and Nebuli/er Model on Aerosol Output 
During Intermittent Delivery with a Dosimeter — Alkins SA. Hurwitz 
KM. Sierra A. J Aerosol Med 2002 Spring; 1 5{ 1 ): 1 -6. 

Recent guidelines reinforce the need for a standardized technique during 
inhalational bronchoprovocation challenge testing. We investigated the 
effects of nebulizer model and dosimeter driving pressure on nebulizer 
output using a nebulized saline model. Four nebulizers {Hudson 1720, 
Salter ,S9()0. Baxter Airlife. and DeVilbiss 644) were evaluated at two 
driving pressures (20 and 50 pounds per square inch [psi]) via a dosimeter 
(Sailer 700) that delivered a 0.6-sec actuation. Output was determined 
gravimetrically after 20 actuations of saline at constant respiratory flow 
and volume. Output per actuation al 20 psi was 2.83 ± 0.41 mg (mean ± 
SD), 4.58 ± 0.66, 4.75 ± 0.42. and 4.75 ± 1.37 for the Hudson, Salter, 
Baxter, and DeVilbiss. respectively, and 6.75 ± 0.61 mg. 9.17 + 0.88. 
9.42 ± 1 .32, and 9.83 ± 1 .75 al 50 psi. The Hudson delivered a lower vol- 
ume than the other nebulizers (p < O.OOOS). At 20 psi. output from the 
DeVilbiss had grealer variability {coefficient of variation = 28. 8";;- ) com- 

pared to the Baxter {CV = 8.8";^ ; p = 0.045 ), The output was greater at 50 
psi than 20 psi for all models {p < 0.{K)05). These results demonstrate that, 
when choosing a nebulizer driven by a dosimeter, it is important to base 
that selection on published data describing aerosol output under different 
driving pressures. 

The Eflect of Inlet Gas Temperatures on Heated Humidifier Perfor- 
mance — Carter BO. Whittington N. Hochmann M. Osborne A. J Aerosol 

The aim of the current study was to determme the temperature range of 
gas at the point at which it passes into a heated humidifier within an inten- 
sive care unit and to experimentally examine the effect of different inlet 
gas temperatures on the performance of a heated humidifier. Various gas 
and ambient temperatures were measured in an intensive care unit and 
within ventilator circuits. Ventilator oxygen and air inlet temperatures, 
ventilator gas outlet temperatures, and humidifier gas inlet temperatures 
were measured in conjunction with the use of a number of ventilators. 
Ambient temperatures within the ward ranged from 22.8 ° C to 28.9 ° C. 
while typical ward humidifier gas inlet temperatures ranged from 24.3 " C 
to 28.8 ° C. Humidity output from a heated humidifier was then deter- 
mined in an experimental setup at controlled levels of inlet gas tempera- 
ture using a constant gas flow. A decrease in humidity production, from 
approximately 36 mg/L al a humidifier inlet gas temperature of 1 8 ° C, to 
26 mg/L at a humidifier inlet gas temperature of 32 ° C, was observed 
with increasing gas inlet temperature. We conclude that humidity output 
from a heated humidifier varies with inlet gas temperature, decreasing as 
inlet gas temperature increases. Inlet gas temperatures above 26 ° C may 
result in inadequate humidification. 

Patient Perception and .Acceptability of Multidose Dry Powder 
Inhalers: A Randomized Crossover Comparison of Diskus/ 
Accuhaler with Turhuhaler — Serra-Batlles J. Plaza V. Badiola C. 
Morejon E; Inhalation De\ices Study Group. J Aerosol Med 2002 
Spring:15( 11:59-64. 

This study was designed to prov ide information on correct use and prefer- 
ence to features and device handling of two multidose dry powder 
inhalers, the Disku,s/Accuhaler and the Turbuhaler. A total of 169 pow- 
der-naive patients ( mean age 40 years) with asthma or chronic obstructive 
pulmonary disease (COPD) were enrolled in a randomized crossover 
comparison of both inhalers. An effective use of either inhaler was 
assessed before (leafiel only) and after inhaler education. Ease of use 
especially during an attack and the presence of a dose counter were 
regarded as the most important features for an ideal inhaler. The percent- 
age of correct handling maneuvers and the percentage of patients achiev- 
ing lOO^r of correct maneuvers increased significantly (p < 0.(K)1 ) after 
inhaler education in both devices, but percentage of correct use after the 
intervention was significantly higher for the Diskus/Accuhaler (92.6'J) 
than for the Turbuhaler (89.8<7r: p = 0.036). Overall 609f- of patients 
thought the Diskus/Accuhaler was preferable to the Turbuhaler (p < 
0.001 ). The main reasons given were presence of a dose counter, per- 
ceived ease of use including ease of leai'ning to use, design, and attached 
cover. Among those who preferred the Turbuhaler device, the main rea- 
son cited was small size, discreetness, and ease of holding. In the multi- 
variate analysis, inhaler education (p = 0.005) and education level (p = 
0.009) were significantly associated with the percentage of correct 
maneuvers. Age, sex, or tested inhaler showed no effect on appropriate- 
ness of the inhalation technique. 

Mass Output and Particle Size Distribution of Glucocorticosteroids 
Fniitled from Different Inhalation Devices Depending on \'ari(>us 
Inspiratory Parameters K.imin WE. Genz T. Roedcr S. Scheuch G. 
Trammer T, Juenem.inn R. Cloes RM. J Aerosol Med 2002 
Spring; 15( I ):65-73. 


Respiratory Care . September 2002 Vol 47 No 9 


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Efficient inhalation therapy depends on successful delivery of the drug 
to the lung. The efficacy of drug delivery is not only influenced by the 
characteristics of the inhalation device, but also by the patient's han- 
dling of the device and by the inspiratory maneuver achieved through 
the device. We analyzed the output characteristics of three different 
chlorotluorocarbon (CFC)-free breath-actuated inhalers for inhaled glu- 
cocorticosteroids (BUD Turbohaler. FP Diskus/Accuhaler and HFA- 
BDP Autohaler. respectively). Mass output and panicle size distribu- 
tion of drug aerosol delivered by the inhalers were determined 
depending on different inhalation parameters in vitro using an Andersen 
cascade impactor. We found that, beside the peak inspiratory flow 
(PIF). other factors such as flow acceleration and inhalation volume 
also have significant effects on aerosol generation with respect to mass 
output and panicle size distribution. Thus, these parameters should be 
taken into account when a suitable device for an individual patient is to 
be selected. The dependency on inspiratory parameters was most pro- 
nounced for the dry powder inhalers. The Turbohaler showed by far the 
highest variance in particle output (fine particle fraction ranging from 
3.4% to 22.1% of label claim), whereas the Diskus was less dependent 
on variations in inhalation (10.6% to 18.5% of label claim). The most 
constant aerosol output was found for the Autohaler. which also 
released the highest fine particle fraction (43.1% to 56.6% of label 

Patients' Recollections of Stressful Experiences While Receiving Pro- 
longed Mechanical Ventilation in an Intensive Care Unit — Rotondi 
AJ. Chelluri L. Sirio C. Mendelsohn A. Schul/ R. Belle S. et al. Cnt Care 
Med 2002 Apr;30(4):746-752. 

OBJECTIVE; To describe stressful experiences of adult patients who 
received mechanical ventilation for > 48 hrs in an intensive care unit. 
DESIGN: Prospective cohort study. SETTING: Four intensive care units 
within an East Coast tertiary-care university medical center. PATIENTS: 
Patients were 150 adult intensive care unit patients receiving mechanical 
ventilation for > 48 hrs. INTERVENTION: None. MEASUREMENTS 
AND MAIN RESULTS: As part of a study of the long-term outcomes of 
adult patients requiring prolonged mechanical ventilation, we used a 32- 
item questionnaire to collect data on patients' stressful experiences, both 
psychological (e.g.. fearfulness. anxiety) and physical (e.g.. pain, diffi- 
culty breathing), associated with the mechanical ventilation endotracheal 
tube and with being in an intensive care unit. Of 554 patients who met 
study criteria and survived prolonged mechanical ventilation, 150 con- 
sented and were oriented to person, place, and situation. Two thirds of 
these patients remembered the endotracheal tube and/or being in an inten- 
sive care unit. The median numbers of endotracheal tube and intensive 
care unit experiences remembered were 3 (of 7) and y (of 22). respec- 
tively. If a patient remembered an experience in the questionnaire, it was 
likely to be moderately to extremely bothersome. Some of the items that 
many patients found to be moderately to extremely bothersome were 

Respiratory Care . September 2002 vol 47 No 9 



pain. fear, anxiety, laclt of sleep, feeling lense. inabilily In speak/eonimu- 
nicale. lack of conlrol. nightmares, and Innellness. .Stressful experiences 
associated uitli the endotracheal lube were strongly associated with sub- 
jects' experiencing spells ol terror, feeling nervous when left alone, and 
poor sleeping patterns. CONCLUSIONS; Subjects were more likely to 
remember experiences that were moderately to extremely bothersome. 
This might be because the more bothersome experiences were easier to 
recall or because inost of these experiences are common and significant 
stressors to many of these patients. In either case, these data indicate that 
these patients are subject to numerous stressful experiences, which many 
find quite bothersome. This suggests the potential for improved symptom 
management, vvhich could contribute to a less stressful intensive care unit 
stay and impnned patient outcomes. 

Three I'alients \\ ho Asked That Lift Support Be Withheld or With- 
drawn in the Surgical Intensive Care Unit — Luce JM. Crit Care Med 
2002 Apr:-W(4):775-780. 

OBJECTIVE: To illustrate some of the difficulties encountered in the 
transition from restorative to palliative care and in the pursuit of patient 
autonomy in the intensive care unit. DESIGN: A review of the cases of 
three patients who asked that life support be withheld or w ithdrawn. and a 
discussion of the legal and ethical implications of these cases. SETTING: 
A surgical intensive care unit in an academically affiliated public hospital 
serving as a Level I trauma center. PATIENTS: Three adults with severe 
injuries who lacked legal surrogates and lost the ability to make medical 
decisions. INTERVENTIONS: Care from the attending surgery and con- 
sultative critical care services, in addition to consultations from the psy- 
chiatry service and the hospital ethics committee. MAIN RESULTS; All 
three patients died after life support was withheld or withdrawn, but not 
without conllicts among the various services. In two cases, decisions that 
the patients may or may not have agreed with were made for them by 
their physicians. In the third case, the patient was not consulted after his 
clinical situation changed. CONCLUSIONS: Patients' wishes change and 
are difficult to know, and even when they are known, physicians may 
have difficulty honoring them. Nevertheless, patient autonomy should be 
respected whene\er possible in the intensive care unit. 

Very Early Extubation in Children After Cardiac Surgery — Kloth 
RL. Baum VC Crit Care Med 2002 Apr;.TO(4):7S7-7'Jl. 

OBJECTIVE: Very early extubation ol children after cardiac surgery has 
been suggested as a safe alternative to prolonged postoperative intubation 
but is still not common practice. Studies of early extubation in children 
may not have described reasons for failure to extubate. or have included 
nonbypass or only low-risk repairs. We present our experience with very 
early extubation in an inclusive group of children after cardiac surgery. 
DESIGN: Retrospective chart review. SETTING: University hospital 
operating room and pediatric intensive care unit (ICU). PATIENTS; A 
total of 102 consecutive children (age <18 yrs) undergoing cardiac 
surgery requiring cardiopulmonary bypass. MAIN RESULTS: Forty- 
eight patients were extubated early (88% in the operating room. 12% on 
arrival in ICU ). Patients extubated late were younger ( 1.^. 8 ± 26.2 vs. 47.6 
± 44.5 months), smaller (8.1 ± 10.7 vs. 17. .5 ± 14.2 kg), and had higher 
ASA scores than patients extubated early (p <(l.()01 for all). The youngest 
patient extubated early was 2 months old (range. 2-192 months). P,,i (>, on 
ICU arrival was higher in the early extubation group (.52.4 ± 6.9 vs. 41.2 
± 14.7 mm Hg |7.() ± 0.9 vs. 5.5 ± 2.0 kPa|. p <0.()()l ). and pH was lower 
(7.27 ± 0.04 vs. 7..^7 ± 0.16. p <0.()01). Use of subarachnoid morphine 
did not affect ability to extubate early. No patients in the early extubation 
group required special airway support, reintubation. or increased 
inotropic suppon after ICU admission. CONCLUSIONS: Successful 
early extubation of even young children is possible and easily accom- 
plished in most children undergoing cardiopulmonary bypass, even with 
complex procedures, but advantages of extubation in the operating room 

vs. immediate ICU extubation remain unclear. Transient niild-to-nioder- 
ate mixed acidosis is common and requires no treatment. Full implemen- 
tation requires acceptance by surgical and ICU staffs. 

Patienl-\ eiitilalor Interactions Durinj; Partial \ enlilatory .Support: 
.\ Preliminary Stud) Comparing the KITects of Adaptive Support 
Ventilation with Synchronized Intermittent Mandatory \'entilatiun 
Plus Inspiratory Pressure Support — Tassaux D. Dalmas E. Gratadour 
P. Jolliet P. Crit Care Med 2002 Apr;.K)(4);8() 1-807. 

OBJECTIVE: To compare the effects of adaptive support ventilation 
(ASV) and synchronized intermittent mandatory ventilation plus pressure 
support (SIMV-PS) on patient-ventilator interactions in patients undergo- 
ing partial ventilatory support. DESIGN; Prospective, crossover interven- 
tional study. SETTING: Medical intensive care unit, university tertiary 
care center. PATIENTS: Ten patients, intubated and mechanically venti- 
lated for acute respiratory failure of diverse causes, in the early weaning 
period, ventilated with SIMV-PS and clinically delectable sternocleido- 
mastoid activity suggesting increased inspiratory load and patient-venti- 
lator dy.ssynchrony. INTERVENTIONS: Measurement of respiratory 
mechanics. P(j |. sternocleidomastoid electromyographic activity, arterial 
blood gases, and systemic hemodynamics in three conditions: 1 ) after 45 
mins with SIMV-PS (SIMV-PS 1); 2) after 45 mins with ASV. set to 
deliver the same minute-ventilation as during SIMV-PS; J) 45 mins after 
return to SIMV-PS (SIMV-PS 2). with settings identical to those of the 
first SIMV-PS period. MAIN RESULTS: The same minute ventilation 
was observed during ASV (11.4 ± 3.1 L/min [mean ± SD)) as during 
SIMV-PS I (1 1.6 + 3.5 L/min) and SIMV-PS 2 (10.8 + 3.4 L/min). No 
parameter was significantly different between SIMV-PS 1 and 2. hence 
subsequent results refer to ASV vs. SIMV-PS 1. During ASV. tidal vol- 
ume increased (538 ±91 vs. 671 ± 100 niL. p<0.05l and total respiratory 
rate decreased (22 ± 7 vs. 17 ± 3 breaths/min. p <0.05) vs. SIMV-PS. 
However, spontaneous respiratory rate increased in six patients, 
decreased in four, and remained unchanged in one. Po i decreased during 
ASV in all patients except three in whom no change was noted ( 1 .8 ± 0.9 
vs. I.I ± 1 cm H3O. p <0.05). During ASV. sternocleidomastoid elec- 
tromyogram activity was markedly reduced (electromyograni index, 
where SIMV-PS 1 = 100. ASV .34 + 41. SIMV-PS 2 89 ± 36. p <0.02) as 
was palpable muscle activity. No changes were noted in arterial blood 
gases. pH. or mean systemic pressure during the trial. CONCLUSION; In 
patients undergoing partial ventilatory suppon. with clinical and elec- 
tromyographic signs of increased respiratory muscle loading. ASV pro- 
vided levels of minute ventilation comparable to those of SIMV-PS. 
However, with ASV, central respiratory drive and sternocleidomastoid 
activity were markedly reduced, suggesting decreased inspiratory load 
and improved patient-ventilator interactions. These preliminary results 
warrant further testing of ASV for partial ventilatory support. 

Percutaneous Tracheostomy: Prospective Comparison of the 
Translarvngeal fechniipie Versus the Forceps-Dilational Technique 
in lot) Critically III Adults— Cantais E. Kaiser E. Le Goff "> . Palmier B. 
Crit Care Med 2002 Apr:30(4):815-SI9. 

OBJECTIVE: To compare two dillerent techniques of percutaneous tra- 
cheostomy; Griggs' forceps-dilational technique and Fantoni's transla- 
ryngeal technique, both performed with the manufacturer's basic kit and 
with bronchoscopic guidance. DESIGN: A prospective, randomized trial 
was designed to compare the two tracheostomy techniques. Critically ill 
patients requiring elective tracheostomy for long-term ventilation were 
randomi/ed for translaryngeal tracheostomy or forceps-dilati<inal tra- 
cheostomy. SETTING: Intensive care unit of a military teaching hospital. 
PATIENTS: A total of 100 adult patients in the intensive care unit who 
were mechanically ventilated. PROCEDURES: All tracheostomy proce- 
dures were performed at the bedside by using a commercially available 
set. The procedures were performed by two surgeons, one for broncho- 


Respiratory Care . September 2002 Vol 47 No 9 


scopic guidance and inaiiageincm of ihc airway and one lor the 
tracheostoiiiN. MliASLlRliMHN IS AND MAIN Ri:SLll.TS: 
The measurements were di\ided into procedure-related vari- 
ables (duration, technical diliicullies. o\>i;enalionl: major and 
minor complications. The procedure was longer in the iransla- 
ryngeal technique group (12.9 vs. 6.y mins. p =0.0018). Tech- 
nical dilTiculties occurred in 1 1 patients in the translaryngeal 
technique group. Uneventful forceps dilational tracheostomy 
was performed instead. There has been no mortality associated 
with either technique. Serious complications occurred in one 
patient in the forceps-dilational technique group (one posterior 
tracheal wall injury) and in four patients in the translaryngeal 
technique group (one with a posterior tracheal wall injury and 
three with severe hypoxia). Significant hypercarbia and acido- 
sis occurred in both the translaryngeal technique group and the 
forceps-dilational technique group. A significant decrease in 
PaO-i wtis observed in the translaryngeal technique group (.^1 1 
to 261. p =0.006')). No bleeding requiring intervention 
occurred. CONCLUSIONS: Serious complications related to 
percutaneous tracheostomy occurred in S.^'i and \.H'i of the 
cases in the translaryngeal technique and the forceps-dilational 
technique group. respecti\ely (p <0.00l ). Technical difficulties 
were not rare when using the translaryngeal technique {2y/r). 
On the basis of our results, we concluded thai the forceps-dila- 
tion technique is superior to the translaryngeal technique, with 
fewer technical difficulties and fewer complications for criti- 
cally ill patients. 

Frequency and Determinants of Drug Administration 

Errors in the Intensive Care Unit — van den Benit PM, Fijn 
R. van dcr Voort PH. Gossen AA. Egberts TC. Brouwers JR. 
Crit Care Med 2002 Apr:.^0(4):846-850. 


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VSitshinston, DC 20010. Fax: 202.884..^466. E-mail: HOI:. M/K/1)A. 

OBJECTI'VE: The study aimed to identify both the frequency 
and the determinants of drug administration errors in the inten- ^^^^^ 
sive care unit. DESIGN: Administration errors were detected ^^^^™ 
by using the disguised-observation technique (observation of 
medication administrations by nurses, without revealing the 
aim of this observation to the nurses). SETTING: Two Dutch 
hospitals. P.-\TIENTS: The drug administrations lo patients in the inten- 
sive care units of two Dutch hospitals were observed during five consecu- 
RESULTS: A total of 233 medications for 24 patients were observed to 
be administered (whether ordered or not) or were observed to be omitted. 
When wrong time errors were included, 104 administrations with at least 
one error were observed (frequency. 44.6'?), and when they were 
excluded. 77 administrations with at least one error were observed (fre- 
quency. 33.0'/r). When we Included wrong time errors, day of the week 
(Monday, odds ratio lORl 2.64. confidence interval ICIl l.42-.'i.lO). time 
of day (6-10 pm. OR 0.28. CI 0.10-0.78). and drug class (gastrointestinal. 
OR 2.94, CI 1 .48-5.85; blood. OR 0. 12. CI 0.03-0.54; and cardiovascular. 
OR 0.38. Cl.0. 16-0.90) were associated with the occurrence of errors. 
When we excluded wrong time errors, day of the week (Monday. OR 
3.14. CI 1.66-5.94), drug class (gastrointestinal, OR 3,47. CI 1.76-6.82; 
blood. OR 0.21. CI 0.05-0.91: and respiratory. OR 0.22. CI 0.08-0.60). 
and route of administration (oral by gastric tube. OR 5.60. CI 1.70-18.49) 
were associated w ilh the occurrence of errors. In the hospital w ilhout lull- 
time specialized intensive care physicians (which also lacks pharmacy- 
provided protocols for the preparation of parenteral drugs), more admin- 
istration errors occurred, both when we included (OR 5.45, CI 3.04-9.78) 
and excluded wrong time errors (OR 4.22. CI 2.36-7.54). CONCLU- 
SIONS: Efforts to reduce drug administration errors in the intensive care 
unit should be aimed at the risk factors we identified in this study. Espe- 
cially, focusing on system differences between the two intensive care 
units (e.g., presence or absence of full-time specialized intensive care 

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physicians, presence or absence of protocols for the preparation of all par- 
enteral drugs) may help reduce suboplimal drug administration. 

Importance of Hypoxic Vasoconstriction in Maintaining Oxygena- 
tion During Acute Lung Injury- Bnmioulle S. Julicn V. Gusi R. 
Kozlowski JK, Naeije R, Schusier DP. Crit Care Med 2002 

OBJECTIVE: To investigate the role of hypoxic pulmonary vasoconstric- 
tion in the intrapulmonary blood fiow redistribution and gas exchange 
protection during oleic acid acute lung injury. DESIGN: Prospective, 
controlled animal study. SETTING: Research laboratory of an academic 
mstitution. SUBJECTS: Three groups of five mongrel dogs. INTER- 
VENTIONS: Induction of acute lung injury by 0.08 mLikg oleic acid 
intravenously. Hypoxic pulmonary vasoconstriction inhibition by 
Escherichia coli endotoxin microdose (15 microg/kg) pretrealment or by 
metabolic alkalosis (pH 7.60). MEASUREMENTS AND MAIN 
RESULTS: Pulm<inary arterial and venous resistances were determined 
by fiow-pressure curves and by capillary pressure estimation. Regional 
lung water and pulmonary blood fiow were assessed by positron emission 
tomography. Oleic acid alone increased Ihe arterial and venous resis- 
tances, redistributed blood flow away from edematous areas, and 
decreased the P.,o, from 507 + 1 6 to 373 ± 60 (orr on I-'io, 1 .0 and positive 
end-expiratory pressure 5 cm HiO. Endotoxin pretrealment inhibited the 
increase in arterial resistance, suppressed the redisiribulion. and 
decreased the Pji, to 105 ± 22 Uirr. Alkalosis inhibited the increase in 

Respiratory Care . September 2002 Vol 47 No 9 



arterial and venous resistances, suppressed the redistribution, and 
decreased the Pao-, to 63 ± 12 torr. Reversal of the alkalosis increased the 
arterial and venous resistances, restored the perfusion redisuibution, and 
improved the PjOt l" 372 ± 63 torr. Changes in blood gases conformed to 
predictions of a computer lung model in which hypoxic pulmonary vaso- 
constriction was suppressed by endotoxin and alkalosis. CONCLU- 
SIONS: We conclude that in oleic acid-induced lung injury, a) pulmonary- 
hypertension results from increases in both arterial and venous resis- 
tances; b) the increase in arterial resistance is the primary mechanism 
responsible for the perfusion redistribution and the gas exchange protec- 
tion; and c) the increase in arterial resistance is most consistent with 
hypoxic pulmonary vasoconstriction. 

Impact of a Pediatric Clinical in tlie Pediatric Intensive 
Care Unit — Krupicka Ml, Bratton SL, Sonnenthal K. Goldstein B. Crit 
Care Med 2002 Apr;30(4):9 19-921. 

OBJECTIVE: To study the impact of a clinical pharmacist in a pediatric 
intensive care unit. The goals of the study were to determine the type and 
quantity of patient care interventions recommended by a clinical pharma- 
cist and to specifically examine cost savings (or loss) that resulted from 
clinical pharmacist recommendations. DESIGN: A prospective case 
series. SETTING: Ten-bed pediatric intensive care unit in a university- 
affiliated children's hospital. PATIENTS: All patients admitted to the 
pediatric intensive care unit during the study period. INTERVENTIONS: 
study period, the pediatric clinical pharmacist documented all interven- 
tions that occurred dunng her shift. She rounded with the pediatric inten- 
sive care unit team approximately two times a week and reviewed medi- 
cation lists daily. Drug acquisition costs were used to calculate drug cost 
savings. Demographic information was collected on all the patients in the 
pediatric intensive care unit during the study period. There were 35 rec- 
ommendations per 100 patient days. The most common interventions 
were dosage changes (28%). drug information (26%). and miscellaneous 
information (22%). The average time spent per day by the clinical phar- 
macist in the pediatric intensive care unit was 0.73 hrs or 0.02 full-time 
equivalent. The total cost direct savings for the study period was SI. 977. 
Extrapolated to direct cost savings per year, the total amount saved was 
$9, 135/year or 0.15 full-time equivalent. Indirect savings from educa- 
tional activities, avoidance of medication errors, and optimization of 
medical therapies represent an additional nonquantifiable amount. CON- 
CLUSION: We conclude that a clinical pharmacist is an important and 
cost-effective member of the pediatric intensive care unit team. 

Expanding Automatic External Defibrillators to Include Automated 
Detection of Cardiac, Respiratory, and Cardiorespiratory Arrest — 

Pellis T. Bisera J. Tang W, Weil MH. Crit Care Med 2002 Apr;30(4 

The new Guidelines of the American Heart Association state that lay res- 
cuers can no longer rely on the manual pulse check to confirm cardiac 
arrest in an unresponsive patient. We were therefore prompted to develop 
a method for automated detennination of the presence or absence of car- 
diac contraction and breathing. The technique was designed to be incor- 
porated into conventional automated external defibrillators and to work in 
conjunction with the information derived from rhythm analyses by the 
automated defibrillator. Using conventional electrocardiographic sensing 
and defibrillation electrodes, the transthoracic impedance was measured 
by passing a constant amplitude alternating current of 5 mA through the 
thorax at a frequency of 35 kHz. In five anesthetized male domestic 
swine, we observed pulses that were coincident with cardiac contraction 
documented by esophageal echocardiography. In addition, we observed 
larger signals of lower frequency that were time related to ventilation and 
documented by capnography. Both signals disappeared after inducing 
ventricular fibrillation. The impedance measurement Identified respira- 

tory arrest in anesthetized animals and primary cardiac arrest after ven- 
tricular fibrillation was induced. The cardiac arrest detector is therefore 
likely to augment the current information provided by automated defibril- 
lators and to allow for more precise verbal prompting of lay rescuers. 

Pulmonary Dead-Space Fraction As a Risit Factor for Death in the 
Acute Respiratory Distress Syndrome — Nuckton TJ. Alonso JA, 
Kallet RH, Daniel BM. Pittet JF, Eisner MD, Matthay MA. N Engl J Med 

2002 Apr 25:346(1 7 ): 1 28 1 - 1 286. 

BACKGROUND: No single pulmonary -specific variable, including the 
severity of hypoxemia, has been found to predict the risk of death inde- 
pendently when measured early in the course of the acute respiratory dis- 
tress syndrome. Because an increase in the pulmonary dead-space frac- 
tion has been described in observational studies of the syndrome, we 
systematically measured the dead-space fraction early in the course of the 
illness and evaluated its potential association with the risk of death. 
METHODS: The dead-space fraction was prospectively measured in 179 
intubated patients, a mean (±SD) of 10.9±7.4 hours after the acute respi- 
ratory distress syndrome had developed. Additional clinical and physio- 
logical variables were analyzed with the use of multiple logistic regres- 
sion. The study outcome was mortality before hospital discharge. 
RESULTS: The mean dead-space fraction was markedly elevated 
(0.58+0.09) early in the course of the acute respiratory distress syndrome 
and was higher among patients who died than among those who sur\ ived 
(0.63±0.10 vs. 0.54±0.09, p<0.001l. The dead-space fraction was an 
independent risk factor for death: for every 0.05 increase, the odds of 
death increased by 45 percent (odds ratio, 1.45; 95 percent confidence 
interval, 1.15 to 1.83; p=0.002). The only other independent predictors of 
an increased risk of death were the Simplified Acute Physiology Score II, 
an indicator of the severity of illness (odds ratio, 1.06; 95 % confidence 
interval, 1.03 to 1.08; p<0.001) and quasistatic respiratory compliance 
(odds ratio, 1.06; 95 percent confidence interval, 1.01 to 1.10; p=0.01). 
CONCLUSIONS: Increased dead-space fraction is a feature of the early 
phase of the acute respiratory distress syndrome. Elevated values are 
associated with an increased risk of death. 

Predictors of Sleep-Disordered Breathing in Community-Dwelling 
Adults: The Sleep Heart Health Study— Young T, Shahar E, Nieto FJ, 
Redline S, Newman AB, Gottlieb DJ, et al; Sleep Heart Health Study 
Research Group, Arch Intern Med 2002 Apr 22;l62(8);893-900. 

BACKGROUND: Sleep-disordered breathing (SDB) is common, but 
largely undiagnosed in the general population. Information on demo- 
graphic patterns of SDB occurrence and its predictive factors in the gen- 
eral population is needed to target high-risk groups that may benefit from 
diagnosis. METHODS: The sample comprised 5615 community- 
dwelling men and women aged between 40 and 98 years who were 
enrolled in the Sleep Heart Health Study. Data were collected by ques- 
tionnaire, clinical examinations, and in-home polysomnography. Sleep- 
disordered breathing status was based on the average number of apnea 
and hypopnea episodes per hour of sleep (apnea-hypopnea index |AHI|). 
We used multiple logistic regression modeling to estimate cross-sectional 
associations of selected participant characteristics with SDB defined by 
an AHI of 15 or greater. RESULTS: Male sex. age. body mass index, 
neck girth, snoring, and repeated breathing pause frequency were inde- 
pendent, significant correlates of an AHI of 15 or greater. People report- 
ing habitual snoring, loud snoring, and frequent breathing pauses were 3 
to 4 times more likely to have an AHI of 1 5 or greater vs an AHI < 1 5, but 
there were weaker associations for other factors with an AHI of >I5, The 
odds ratios (95% contldence interval) for an AHI of >15 vs an AHI < 15 
were 1.6 and 1.5, respectively, for 1-SD increments in body mass index 
and neck girth. As age increased, the magnitude of associations for SDB 
and body habitus, snoring, and breathing pauses decreased. CONCLU- 
SIONS: A significant proportion of occult SDB in the general population 


Respiratory Care . September 2002 Vol 47 No 9 


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would be missed if screening or case finding were based solely on 
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is needed. 

Evaluation of Restorative Care vs Usual Care for Older .\dults 
Rccclvinf; an Acute Episode of Home Care — Tinetti ME. Baker D. 
Gallo \\r. Nanda A. Charpenlicr P. O'Leary J. JAMA 2002 Apr 

CONTEXT: Illness and hospitalization often trigger functional decline 
among older persons. Home care services implemented for functional 
decline provide an opportunity to intervene to improve outcomes. 
OBJECTIVE: To compare functional status and the likelihood of remain- 
ing at home for persons receiving restorative care vs usual home care. 
DESIGN AND SETTING: Intervention using prospective individual 
matching conducted between November I. 1998. and April 30. 2000. Six 
offices of a home care agency in Connecticut were used. One branch 
office served as the restorative care unit and the other 5 served as usual 
care offices. PARTICIPANTS: Patients receiving home care through the 
restorative care office who were 65 years or older; in receipt of Medicare- 
covered home care lasting at least 7 days; with absence of severe cogni- 
tive iinpairment; and not terminal, bedridden, or requiring total care were 
matched w ith patients from one of the usual care offices. The matching 
factors included age. sex. race, baseline self-care function, cognitive sta- 
tus, whether hospitalization preceded the home care episode, and date of 
the home care episode. Of the 712 eligible restorative care patients. 691 
(979f) were matched with a usual care patient. INTERVENTION: 
Restorative care, provided by the home care agency nursing, therapy, and 
home health aide staff, was based on principles from geriatric medicine, 
nursing, rehabilitation, and goal attainment. MAIN OUTCOME MEA- 
SURES: Remaining at home, functional status at completion of the home 
care episode, and duration and intensity of home care episode. 
RESULTS: Compared with usual care, and after adjusting for baseline 
characteristics and other factors, restorative care was associated with a 
greater likelihood of remaining at home (82%^ vs 7I'7f ; odds ratio [OR]. 
1.99; 959c confidence interval [CI]. 1.47-2.69) and a reduced likelihood 
of visiting an emergency department (10% vs 20%; OR. 0.44; 95% CI. 
0.32-0.61). Home care episodes were shorter (mean |SD]. 24.8 [26.8] 
days vs 34.3 [44.2] days; S = - 1 7 82 1 ; p<0.00 1 ). Restorative care patients 
had better mean (SD) scores than usual care patients in self-care (1 1.0 
[2.1] vs 10.7 [2.5]; p =0.07 after adiustment). home management (9.5 
[2.9] vs 9.2 [3.0]; p =0.05 after adjustment), and mobility (3.3 [0.8] vs 3.2 
[0.9]; p =0.02 after adjustment). CONCLUSIONS: This trial suggests 
that reorganizing the structure and goals of home c;ire can enhance health 
outcomes of older patients w iihcnil increasing health care utilization. 

.Assessing Meaningful Change in (Quality of Life over Time: A Users' 
Guide for Clinicians — Sprangers MA. Moinpour CM, Moynihan TJ. 
Patrick DL. Revicki DA; Clinical Significance Consensus Meeting 
Group. Mayo Clin Proc 2002 Jun;77(6):561-57l. 

The objective of this article is to help clinicians interpret trial-based qual- 
ity of life (QOL) changes overtime. We ;iddress a series of questions and 
provide guidelines that are fundamental to assessing and interpreting 
change. The issues addressed are as follows: ( 1 ) What are the characteris- 
tics of the population for whom changes in QOL are reported? (2) Is the 
QOL questionnaire reliable, valid, and responsive to change? (3) Are the 
timing and frequency of assessments adequate? (4) Is the study ade- 
quately powered'.' (5) How are multiple QOL outcomes addressed in anal- 
yses'.' (6) How are multiple time points handled? (7) Can alternative 
explanations account for the observed change or lack of observed change 
(eg. handling of missing data, survival differences, and changes in 
patient's QOL perspective over time)? and (8) How is statistical signifi- 

cance translated into meaningful change'.' These guidelines will support 
clinicians in reviewing the clinical trial literature, which in turn can help 
them use the data in the treatment decision process. 

The Clinical Significance of Quality-of-Life Results: Practical Con- 
siderations for .Specific .\udiences — Symonds T. Berzon R. Marquis P. 
Runnnans TA; Clinical Significance Consensus Meeting Group. Mayo 
Clin Proc 2002 Jun:77(6):572-583. 

This is the sixth article in a series intended to summarize the state of the 
science for assessing the clinical significance of quality-ol'-life (QOL) 
assessments. The previous 5 articles dealt with specific methodological 
issues, whereas this article addresses practical considerations in imple- 
menting the methods and presenting the results to various audiences with 
differing perspectives. Proposals for how to interpret the "clinical signifi- 
cance" or "clinical meaningfulness" of changes in QOL scores were 
addressed in previous articles within this series. Within this article. 4 
audiences — patients and physicians, clinical researchers, health policy- 
makers, and private- and public-sector employees who work in health- 
related fields — are examined because each is a unique stakeholder w ith a 
distinct vantage point and each can interpret QOL outcomes differently. 
A clinician may attempt to explain to a patient potential treatment alterna- 
tives for his or her QOL; a health policymaker may try to describe to 
elected officials the financial impact on a patient population with reduced 
QOL: a researcher may try to obtain the vital messages from a clinical 
trial that included QOL end points: and a regulatory agency and/or phar- 
maceutical company may try to ascertain the appropriate level of evi- 
dence required for a successful research study. For each of the 4 audi- 
ences, concrete examples and practical guidelines are offered by which 
changes in QOL outcomes can be interpreted meaningfully. Ultimately, 
both determining and disseminating the meaning of clinical significance 
are functions of the outlook of the audience because the perspective of the 
audience determines its ability to comprehend, evaluate, and convey the 
context within which such outcomes appear meaningful. Among the 
audiences described within this article, a commonality of interests exist 
that mandates a careful exposition of the scientific rigor involved in 
describing the clinical significance of QOL assessments. Collectively, 
this series attempts to provide methods and means for making such deter- 

Music and Preoperative Anxiety: A Randomized, Controlled 

Study— Wang SM. Kulkarni L. Dolev J. Kain ZN. Anesth Analg 2002 

Music may decrease the anxiety experienced by patients before surgery. 
Previous studies of this issue were hindered w ith multiple methodological 
problems. In this investigation, we examined this hypothesis while using 
a rigorous study design and objective outcome measures. Adult patients 
undergoing anesthesia and surgery were randomly assigned to two study 
groups. Subjects in Group I (n = 48) listened to a 30-min patient-selected 
music session, and subjects in Group 2 (n = 45) received no intervention. 
By using self-report valid;Ued behavioral (State-Trait Anxiety Inventory) 
and physiological measures of anxiety (heart rate, blood pressure, and 
electrodermal activity and serum Cortisol, epinephrine, and nore- 
pinephrine), patients were evaluated before, during, and after administra- 
tion of the intervention. We found that after intervention, subjects in the 
Music group reported significantly lower anxiety levels as compared with 
the Control group (F(l.91) = 15.4. p = 0.001 ). That is. the postinterven- 
tion anxiety level of subjects in the Music group decreased by 16% as 
compared with the preintervention level, whereas the anxiety level of the 
Control group did not change significantly. Two-way repeated-measures 
analysis of variance performed for the electrodermal activ ity. blood pres- 
sure, heart rate. Cortisol, and catecholamine data demonstrated no group 
difference and no time x group interaction (p = not significant). In conclu- 
sion, under the conditions of this study, patients who listened to music 


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bclorc surgery reported lower levels ol stale anxiety. Physiological oul- 
comes did not differ, however, between the two study groups. IMPLICA- 
TIONS: Patients who listen to music of their choice during the preopera- 
tive period report less an.xiety. 

Pressure .Support Compared with Controlled Mechanical Ventila- 
tion In Kxperiniental l.unj; Injury — Denihuiski R, Max M. Bensberg 

R. Rossanit R. Kuhlen R. ,^nesth Analii 20(12 Jun;94(6l: I ,S70- 1 .S76. 

increasing COHb. The anemia adjustment was proportional to the frac- 
tional COHb. DI. adjusted for FAco- was unaffected by increasing 
COHb. We conclude that DLcosr must be adjusted for both the buildup 
of CO backpressure and the anemia effect of increasing COHb. Adequate 
corrections of DLfosB can be implenienled using FAco measured during 
a standardized deep breath immediately preceding the DLcosb maneuver. 
Current American Thoracic Society recommendations for DLcqsb stan- 
dardization do not adei.|uately compensate for COHb. 

It has been suggested that, in acute lung injury (ALI), spontaneous 
breathing activity may increase oxygenation because of an improvement 
of ventilation-perfusion distribution. Pressure support ventilation (PSVl 
is one of the assisted spontaneous breathing modes often used in critical 
care medicine. We sought to delcrmine the prolonged effects of PSV on 
gas exchange in experimental ALI. We hypothesized that PSV may 
increase oxygenation because of an improvement in ventilation-perfusion 
distribution. Thus, ALI was induced in 2(1 pigs by using repetitive lung 
lavage. Thereafter, the animals were randomized to receive either PSV 
with a pressure level set to achieve a tidal volume >4 mL/kg and a respi- 
ratory rate <40 min' (n = 10) or controlled mechanical ventilation 
(CMV) with a tidal volume of 10 mL/kg and a respiratory rate of 20 min ' 
(n = 10). Positive end-expiratory pressure was set at 10 cm HiO in both 
groups. Blood gas analyses and determination of ventilation-perfusion 
(Va/Q) distribution were performed at the onset of ALI and after 2, 4, S, 
and 12 h. The main result was an improvement of oxygenation because of 
a decrease of pulmonary shunt and an increase of areas with normal . 
Va/Q ratios during PSV (p < 0.0051. However, during CMV. a more pro- 
nounced reduction of shunt was observed compared with PSV (p < 
0.005). We conclude that, in this model of ALI, PSV improves gas 
exchange because of a reduction of Va/Q inequality. However, improve- 
ments in Va/Q distribution may be more effective with CMV than with 
PSV. IMPLICATIONS: Assisted spontaneous breathing may have bene- 
ficial effects on gas exchange in acute lung injury. We tested this hypoth- 
esis for pressure support ventilation in an animal model of acute lung 
injury. Our results demonstrate that pressure support does not necessarily 
provide better gas exchange than controlled mechanical ventilation. 

The Treatment of Severe Pulmonary Edema Induced by I! .\drener- 
gic .Agonist Tocolytic Therapy with Continuous Positive Airway 
Pressure Delivered hy Face Mask — de La Chapelle A, Benoit S, 
Bouregba M, Durand-Reville M. Raucoules-Aime M. Anesth Analg 2002 

IMPLICATIONS: We report the case of a pregnant patient who devel- 
oped severe pulmonary edema secondary to beta-adrenergic agonist 
tocolytic therapy (salbutamol) and was successfully treated with mask- 
delivered continuous positive airway pressure ventilation. 

Effects of Increasing Carboxyhemoglobin on the Single Breath Car- 
bon Monoxide Diffusing Capacity — Graham BL. Mink JT. Cotton DJ. 
Am .1 Rcspir Crit Care Med 2002 Jun I ; 1 65( I 1 1: 1 504- 1 5 1 0. 

Although carboxyhemoglobin (COHhl is often increased in smokers, 
American Thoracic Society recommendations for adjusting the single 
breath carbon monoxide (CO) diffusing capacity (DLcosb) f>'r COHb 
remain optional. Using a previously described .^-equation technique, we 
measured Dl<-osB and an index of diffusion inhomogeneity (Dll in 10 
healthy, nonsmoking subjects who performed DLcosb maneuvers both 
before and after increasing COHb. CO backpressure (FAcol was mea- 
sured from the exhaled gas of a standardized deep brealh of room air that 
immediately preceded each DLcosb and was validated hy measurement 
of FAco from an identical "sham" maneuver wilhout inhaling CO. With- 
out adjustments for FAco or COHb. DLcosn decreased with increasing 
COHb. This effect persisted when DLcosn was adjusted only for FAco- 
but it was cliininak'd with further ad|ustiiient for the anemia effect of 

Kespiratory Impedance Response to a Deep Inhalation in Children 
with History of Cough or Asthma — Marchal F, Schweitzer C. Moreau- 
Colson C. Pediatr Pulmonol 2002 Jun:.^.^(fil:41 1-418. 

The aim of this study was to describe the change in respiratory impedance 
induced by a deep inhalation (Dll in children who developed a positive 
response to inhalation of methacholine (Mchl. Eighteen children aged 
4.5- 1 2.5 years, presenting with chronic cough or doctor-diagnosed 
asthma, were studied at baseline after inhalation of Mch and after inhala- 
tion of a bronchodilator. Respiratory resistance (Rrsl and reactance (Xrs) 
were measured by the forced oscillation technique, varying transrespira- 
tory pressure at 12 Hz around the head. The tidal flow (V) and volume 
(Vl dependence of Rrs before and after the DI was characterized accord- 
ing to the equation Rrs = K 1 -i- K2 x /V/ ■(■ K.^ x V. DI induced no signifi- 
cant change at baseline or after inhalation of abonchodilator. During Mch 
challenge. Rrs and Kl were significantly lower, and K3 and Xrs signifi- 
cantly less negati\e after DI than before, during both inspiration and expi- 
ration; there was no change in K2.We conclude that DI results in a 
decrea,se in Rrs in children with induced bronchoconstriction. The associ- 
ated changes in Xrs. Kl, and K3. and lack of decrease in K2. suggest that 
dilatation of airways occurs at the bronchial level, with little contribution 
of the upper airways or of a change in breathing patterns. 

Exploring the Relationship Between Forced Maximal Flow at Func- 
tional Residual Capacity and Parameters of Forced Expiration from 
Raised Lung \ olume in Healthy Infants — Ranganathan SC. Hoo AF. 
Lum SY. Goetz I. Castle RA, Stocks J. Pediatr Pulmonol 2002 

The raised volume rapid thoraco-abdominal compression technique 
(RVRTCl is being increasingly used to assess airway function in infants, 
but as yet no consensus exists regarding the equipment, methods, or anal- 
ysis of recorded data. The aim of this study was to explore the relation- 
ship between maximal fiow at functional residual capacity (VnnxFRc) iind 
parameters derived from raised lung volumes, and to address analytical 
aspects of the latter technique in an attempt to assist with future standard- 
ization initiatives. Forced vital capacity (FVC) from lung volume raised 
to 3 kPa. timed forced expiratory volumes (FEV,). and forced expiratory 
fiow parameters at different percentages of expired FVC (FEFf-, ) were 
measured in 98 healthy infants (1-69 weeks of age). V„i;hprc using the 
tidal rapid thoraco-abdominal compression (RTCl technique was also 
measured. The within-subject relationships and within-subject variability 
of the various parameters were assessed. Duration of lorced expiration 
was < 0.5 sec in 5 infants, meaning that FEVn i and FEV114 were the only 
timed volume parameters that could be calculated in all infants during the 
first months of life, and even when it could be calculated, FEVu^ 
approached FVC in many of these infants. It is recommended that FEV04 
be routinely reported in infants less than 3 months of age. Contrary to pre- 
vious reports, within subject variability of V,„a^pRc was less than that of 
FEF7S (mean CV = (i.y:i and 8.9'/r. respectivelyl.A more standardized 
protocol when analyzing data from the RVRTC would lacilitate compar- 
isons of results between centers in the future. 

.Attenuation of Pressure Swings Along the Endotracheal Tube Is 
lndicati\e of Optimal Distending Pressure During High-Frcquency 
Oscillatory Ventilation in a Model of Acute Lung Injury — Van Gen- 


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dcringcn HR. Van Vuiihl AJ. Duval Fl., Markhorst DG. Jansen JR. Pedi- 
atr Puliiionol :()(): .liin:.V^(fi):42y-436. 

We leMed the hypiuhesis ihal during liigh-tVec|uency oseillator> ventila- 
tion, the oscillatory pressure ratio (OPR) is minimal at the optimal mean 
airway pressure (Paw). OPR is defined as the ratio of pressure swings at 
the distal end and the proximal opening of the endotracheal tube. Optimal 
Paw was assumed to be the lowest Paw at which the physiological shunt 
fraction «as below 0.1. Acute lung injury was produced by saline lung 
lavage of pigs who were then subjected to a stepwise increase of Paw to 
impose underintlation. optniial inllation. and overdistention (inflation 
phase), followed by a stepwise decrease of Paw (deOation phase). OPR 
reached a minimum of 0.10 ± 0.01 at Paw = 31 ± 4 cm H^O during the 
inflation phase and a minimum of 0.04 ± 0.01 at Paw = 18 ± 1 cm H;0 
during the deflation phase. Optimal Paw was 31 + 4 cm HiO on the infla- 
tion limb and 14 ± 2 cm H^O on the deflation limb. Paw at the minimal 
OPR was not significantly different from the optimal Paw during the 
mllation phase, and slightly but significantly higher (4.1 ± 1.6 cm HiO) 
during the deflation phase. In conclusion, a consistent relationship was 
found between OPR and Paw, with a minimum in all animals. The mini- 
mal OPR coincides fairly well with the Paw where oxygenation is opti- 
mal . 

Predictors of Deterioration of Lung Function in Cystic Fibrosis: This 
\\ ork Was Presented in Part .\s a Poster at the Xlllth International 
Cystic Fibrosis Congress in Stockholm. ,|une 2(M)0 — Schaedel C. De 
Monestrol 1. Hjelte L, Johannesson M, Kornfalt R. Lindblad A, Strandvik 
B. Wahlgren L. Holmberg L. Pediatr Pulmonol 2002 Jun;33(6):483-491. 

operation. RESULTS: A total of I \5 patients with a median forced expi- 
ratory volume in 1 second of 0.73 L (27'i'r of predicted value) underwent 
lung volume reduction surgery. Follow-up extended over a median of 37 
months. Median forced expiratory volume in 1 second significantly 
increased within 6 months after the operation by 379}- in homogeneous (n 
= 27). by 38'7r in intermediately heterogeneous (n = 37). and by 639}- in 
markedly heterogeneous einphysema (n = 51. p <0.05 vs. other mor- 
phologies). Maximal forced expiratory volume in 1 second was reached 
w ithin 6 months after lung volume reduction surgery and decreased in the 
first postopcrali\ e year by 0. 1 6 L per year in homogeneous, by 0. 1 9 L per 
year in intermediately heterogenous, and by 0.32 L per year in markedly 
heterogeneous emphysema (p <0.0I vs. other morphologies). The decline 
in forced expiratory volume in 1 second over subsequent years deceler- 
ated according to an exponential decay and was similar for all morpho- 
logic types (median annual decrease of 0.09 L [9%]). CONCLUSIONS; 
Lung volume reduction surgery improves lung function in severe homo- 
geneous and, to an even greater extent, heterogeneous emphysema. 
Forced expiratory volume in 1 second peaks within 6 months postopera- 
tively. The subsequent decline is most rapid in the first and slows 
down in succeeding years according to an exponential decay. Therefore, 
long-term functional results of lung volume reduction surgery may be 
more fa\orable than expected from linear extrapolations of short-term 

Virtual Bronchoscopy for Evaluation of Malignant Tumors of the 
Thorax — Finkelstein SE. Summers RM, Nguyen DM. Stewart JH 4th, 
Tretler JA, Schrump DS. J Thorac Cardiovasc Surg 2002 

The severity of lung disease in cystic fibrosis (CF) may be related to the 
type of mutation in the cystic fibrosis transmembrane conductance regu- 
lator (CFTR) gene, and to environmental and immunological factors. 
Since pulmonary disease is the main determinant of morbidity and mor- 
tality in CF, it is important to identify factors that can explain and predict 
this variation. The aim of this longitudinal study of the whole Swedish CF 
population over age 7 years was to correlate genetic and clinical data with 
the rate of decline in puhnonary function. The statistical analysis was per- 
formed using the mixed model regression method, supplemented with 
calculation of relative risks for severe lung disease in age cohons.The 
severity of pulmonary disease was to some extent predicted by CFTR 
genotype. Furthermore, the present investigation is the first long-term 
study showing a significantly more rapid deterioration of lung function in 
patients with concomitant diabetes mellitus. Besides diabetes mellitus, 
pancreatic insufficiency and chronic Psciuloimmiis colonization were 
found to be negative predictors of pulmonary function. In contrast to sev- 
eral other reports, we found no significant differences in lung function 
between genders. Patients with pancreatic sufficiency have no or only a 
slight decline of lung function with age once treatment is started, but an 
early diagnosis in this group is desirable. 

(;ain and .Suhsequent Loss of Lung Function .\fltr Lung \ olume 
Reduction Surgery in Cases of Severe Kmphysema with Different 
Morphologic Patterns — Bloch KE, Georgescu CL, Russi EW, Wedcr 
\V J Thoiac Cardiovasc Surg 2002 May;123(.'i|:84.';-8.'54. 

OBJECTIVE: Surgical lung volume reduction improves lung function 
and dyspnea in advanced emphysema to a variable degree. Because long- 
term results with this procedure are scant, we prospectively investigated 
lung function over several years after lung volume reduction surgery with 
regard to einphysema morphology, ME THODS: Bilateral video-assisted 
thoracoscopic lung volume reduction surgery was performed in severely 
sytiiptomatic patients with marked hyperinfiation caused by advanced 
nonhullous emphysema. Emphysema heterogeneity was visually graded 
on chest computed tomography. Symptoms and lung function were 
assessed before the operation and 3, 6, and then every 6 months after the 

OBJECTIVE: Vinual bronchoscopy is a novel technique making use of 
3-dimensional reconstruction of 2-dimensional helical computed tomo- 
graphic images for noninvasive evaluation of the tracheobronchial tree. 
This study was undertaken to evaluate the diagnostic potential of virtual 
bronchoscopy by comparing virtual bronchoscopic images with fiberop- 
tic bronchoscopic findings in patients with thoracic malignant disease. 
METHODS; Thirty-two consecutive patients with thoracic malignant 
tumors underwent virtual bronchoscopy for evaluation of suspected tra- 
cheobronchial lesions. For each virtual bronchoscopic examination, 200 
to 300 contiguous 1,25-mm images of the thorax were obtained in only 
one or two 17-second breath holds by using a multislice computed tomo- 
graphic scanner. Virtual bronchoscopy images were reconstructed and 
interpreted blind to the actual endoscopic findings. Results of virtual 
bronchoscopy were compared with fiberoptic bronchoscopic findings in 
20 patients, RESULTS: Anatomic computer simulation of the bronchial 
tree was successfully created in all patients. In 7 (35'f I of 20 patients, 
results of fiberoptic bronchoscopy were found to be within normal limits. 
In all patients with normal anatomy, virtual bronchoscopy accurately cor- 
related with the fiberoptic findings. Thirteen {by/c ) patients had a total of 
22 abnormal findings on fiberoptic bronchoscopy. Virtual bronchoscopy 
detected 18 of 22 abnormal fiberoptic bronchoscopic findings: 13 of 13 
obstructive lesions. 5 of 6 endoluminal lesions, and of 3 mucosal 
lesions. The sensitivity of virtual bronchoscopy was lOO'/r for obstructive 
lesions, 839r for endoluminal lesions. O'-i for mucosal lesions, and 829}- 
for all abnormalities; the specificity of virtual bronchoscopy was 1009?-, 
CONCLUSIONS; Preliminary evaluation indicates that virtual bron- 
choscopy may be a promising and noninvasive modality for identifying 
bronchial obstructions and endoluminal lesions, as well as for assessing 
the tracheobronchial tree beyond stenoses. However, at present, virtual 
bronchoscopy does not enable the detection of subtle mucosal lesions, 
and as such, this modality may not be appropriate for identifying prema- 
lignant lesions in the respiratory tract. Although fiberoptic bronchoscopy 
remains the standard modality for evaluating airway patency and mucosal 
lesions, virtual bronchoscopy may provide additional information that 
may be useful in the management of pulmonary malignant tumors. 



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Decision to Extubate — Epstein SK. Intensive Care Med 2002 

The need for reintubalion within 24-72 h ol planned extubation is a 
common event, occurring in 2-25% of extubated patients. Risk factors 
for extubation failure include being a medical, multidisciplinary or pae- 
diatric patient; age >70 years; a longer duration of mechanical ventila- 
tion; use of continuous intravenous sedation; and anaemia 
(haemoglobin <10 g/dl or haematocrit <30'/r) at the time of extubation. 
The pathophysiology of extubation failure can be distinct from that seen 
with weaning failure and mcludes upper airway obstruction, inadequate 
cough, excess respiratory secretions, encephalopathy, and cardiac dys- 
function. Extubation failure prolongs the duration of mechanical venti- 
lation, increases the length of ICU and hospital stay, increases the need 
for tracheostomy, and is as.sociated with a higher hospital mortality. 
Great emphasis has been placed on accurately predicting extubation 
outcome because extubation delay is also associated with increased 
length of stay and mortality. Tests designed to assess for upper airway 
obstruction, secretion volume, and the effectiveness of cough seem 
most promising for improving the decision to extubate. Mortality 
increases with delays in reintubation for patients failing extubation. 
Timely identification of patients at elevated risk of extubation failure 
followed by rapid re-establishment of ventilatory support can improve 

Lung Recruitment Maneuver in Patients with Cerebral Injury: 
Effects on Intracranial Pressure and Cerebral Metabolism — Bein 
T. Kuhr LP. Bele S. Ploner F. Keyl C. Taeger K. Intensive Care Med 

OBJECTIVE: To investigate the effects of a lung recruitment maneuver 
on intracranial pressure (ICP) and cerebral metabolism in patients with 
acute cerebral injury and respiratory failure. DESIGN: Prospective 
investigation. SETTING: Ten-bed intensive care unit of a university 
hospital. PATIENTS: Eleven patients with acute traumatic or non-trau- 
matic cerebral lesions, who were on mechanical ventilation with acute 
lung injury. INTERVENTIONS: Heinodynamics. ICP. cerebral perfu- 
sion pressure (CPP). jugular venous oxygen saturation (SJOi). and arte- 
rial minus jugular venous lactate content difference ( AJDL) were mea- 
sured before, during and after a volume recruitment maneuver (VRM). 
which included a 30-s progressive increase in peak pressure up to 60 
cmHiO and a sustained pressure at the same level for the next .30 
s.RESULTS: At the end of VRM. ICP was elevated (16±5 mmHg vs 
13±5 mmHg before VRM. p<0.0.'^) and mean arterial pressure was 
reduced (75±10 vs 86±9 mmHg. p<0.01 ). which resulted in a decrease 
of CPP (60+10 vs 72+8 mmHg. p<0.01 ). SJOi deteriorated at the end of 
the procedure (59±7 vs 69±6%. p<0.0.'i). AJDL was not altered. In the 
following period all parameters returned to normal values. An improve- 
ment in arterial oxygenation was observed at the end. but not in the 
period after the maneuver.CONCLUSlONS: Our VRM reduced cere- 
bral hemodynamics and metabolism. We conclude that our VRM with 
high peak pressure effects only a marginal improvement in oxygenation 
but causes deterioration of cerebral hemodynamics. We therefore can- 
not recominend this technique for the ventilatory management of brain- 
injured patients. 

Iatrogenic Cerebral .Air Embolism: Inipcirtance of an Early Hyper- 
baric Oxygenation — Blanc P. Boussugcs A, Henrieltc K, Sainty JM. 
Deleflie M. Intensive Care Med 2002 May;28(5):559-563. 

OBJECTIVES: To assess the relationship between the time period 
before hyperbaric oxygenation therapy (HBO) and clinical outcome in 
patients with iatrogenic cerebral air embolism. DESIGN AND SET- 
TING: Retrospective study in a hyperbaric chamber and medical inten- 
sive care unit of a university hospital. PATIENTS: All patients with air 

embolism from 1980 to 1999. INTERVENTIONS: We retrieved the 
cases of 86 patients who benefited from an identical HBO and analyzed 
the relationship between the time period before HBO and clinical out- 
come. RESULTS: Patients treated with HBO less than 6 h had a better 
outcome than those treated later. In patients treated within this delay the 
cause was venous air embolism in 84% and arterial air embolism in 
only 16% of cases. After this delay the cause was venous air embolism 
(53%) and arterial air embolism (47%). Patients with venous air 
embolism and recovery had a shorter delay than patients with sequelae 
or death (2 h 15 min vs. 4 h). Patients with venous air embolism treated 
less than 6 h had a better outcome than those treated later. In patients 
with arterial air embolism the time period before HBO was longer than 
in venous air embolism (8 h vs. 3 h) and the outcome worse (recovery in 
35% vs. 67%). In patients with arterial air embolism no difference in 
the time period was found between patients with recovery and sequelae 
or death. CONCLUSIONS: We stress the beneficial effect of an early 
HBO in air embolisin. the importance of an increased awareness of 
physicians concerned with this severe complication, and the need to 
develop techniques to detect air emboli in the cerebral circulation. 

Prone Position .\s Prevention of I.ung Injury in Comatose Patients: 
A Prospective, Randomized, Controlled Study — Beuret P, Carton MJ, 
Nourdine K, Kaaki M. Tramoni G. Ducreux JC. Intensive Care Med 2002 

OBJECTIVE: Comatose patients frequently exhibit pulmonary function 
worsening, especially in cases of pulmonary infection. It appears to have 
a deleterious effect on neurologic outcome. We therefore conducted a 
randomi/ed trial to determine whether daily prone positioning would pre- 
vent lung worsening in these patients. DESIGN: Prospective, random- 
ized, controlled study. SETTING: Sixteen-bed intensive care unit. 
PATIENTS: Fifty-one patients who required invasive mechanical venti- 
lation of coma with Glascow coma scores of 9 or less. INTER- 
VENTIONS: In the prone position (PP) group: prone positioning for 4 h 
once daily until the patients could get up to sit in an armchair; in the 
supine position (SP) group: supine positioning. ME.'XSUREMENTS 
AND RESULTS: The primary end point was the incidence of lung wors- 
ening defined by an increase in the Lung Injury Score of at least 1 point 
since the time of randomization. The secondary end point was the inci- 
dence of ventilator-associated pneumonia (VAP). A total of 25 patients 
were randomly assigned to the PP group and 26 patients to the SP group. 
The characteristics of the patients from the two groups were similar at 
randomization. The incidence of lung worsening was lower in the PP 
group (12%) than in the SP group (50%) ( p=0.003l. The incidence of 
VAP was 20% in the PP group and 38.4% in the SP group (p=0.14l. 
There was no serious complication attributable to prone positioning, 
however, there was a significant increase of intracranial pressure in the 
PP. CONCLUSION: In a .selected population of comatose ventilated 
patients, daily prone positioning reduced the incidence of lung worsen- 

.\ Prospective Sur>cy of Early 12-H Prone Positioning Effects in 
Patients with the .\cute Respiratory Distress Syndrome — L'Her E. 

Renault A. Ogcr K. Robaux MA. Boles JM. Intensive Care Med 2002 

OBJECTIVES: To evaluate of the oxygenation effects of 12-h prone 
positioning (PP) in ARDS patients and to assess the safety of such a pro- 
cedure. DESIGN AND SETTING: Prospective observational study in a 
medical intensive care unit (12 beds) of a university hospital. 
PAT1ENTS:51 consecutive ARDS patients. INTERVENTION: PP for at 
least 12 h daily until recovery or death. MEASUREMENTS AND 
RESULTS: Arterial blood gases were collected before and during PP and 
I h after return to supine. Turning adverse events, cutaneous bedsores, 
and enteral nutrition intolerance were specifically monitored and col- 


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lecteil daily by a referring physician. In total 224 PP sessions were per- 
tornied. Oxygenation improved I h alter the turn and eonliniied improv- 
ing over the 12-h period (4). The hcneticial elTect persisted I h after 
return to supine (01 ). We considered '■Xt'/r patients responders: 45% as 
early responders and 53% persistent responders (persistent benefit 
after return to supine). Four significant adverse events occurred during 
the 44.S turning maneuvers (0.9%). Stage III ulceration and stage IV 
necrosis cutaneous bedsores occurred in ten patients (20%). Enteral 
nutrition intolerance was reported in 25'/r but without inability to meet 
patient's caloric requirement. CONCLUSIONS: Twelve-hour PP is a 
safe procedure and allows a continuous oxygenation improvement 
throughout the entire session. 

Prone Pusitiunin^ in Acute Respiratory Failure: Survey of Belgian 
ICU Nurses — Leonel S. Fontaine C. Moraine JJ. Vincent JL. Intensive 
Care Med 2002 May;28(5):576-580. 

OBJECTIVE:To determine the rrct|uency of use and altitudes towards 
prone positioning in patients with acute respiratory failure. DESIGN 
AND SETTING:Verbal questionnaire survey in all 79 intensive care 
units in French-speaking Belgium. METHODS:Of the 79 ICUs 29 per- 
formed prone-positioning, and 25 agreed to participate in the question- 
naire.MEASUREMENTS AND RESULTSiNurses at 9 of the 25 hos- 
pitals expressed reluctance to use prone positioning. The time 
schedules associated with prone positioning varied among the units 
surveyed, with no consensus. Units used two to six members of staff to 
turn a patient, with three most commonly being employed. Patients 
were most commonly positioned with both arms above the head and 
cushions under the chest, head, and legs, but there was considerable 
variation among units. The ccnnplicalions most commonly reported 
were facial edema and decubitus ulcers, with only three of the units 
reporting accidental extubation. Only two of the units had an estab- 
lished protocol for prone positioning although nurses from 14 of the 
units felt this would be useful. CONCLUS10NS:Prone positioning is 
approached with some reluctance by ICU staff. If the use of prone 
positioning in patients with acute respiratory distress syndrome is 
deemed worthwhile, discussion and development of departmental pro- 
tocols may facilitate its use. 

Short-Term Effects of Expiration Under Positive Pressure in 
Patients with .4cute Kxacerhation of Chronic Obstructive Pul- 
monary Disease and Mild Acidosis Requiring Non-Invasive Positive 
Pressure Ventilation — Bellone A. Spagnolatti L, Massobrio M, Bellei 
E, Vinciguerra R. Barbieri A. et al. Intensive Care Med 2002 
May;28(5 1:58 1-585. 

pared with group B (4.7±2.5 g). The total length of weaning time was 
significantly lower in group A (4.9±0.K days! versus group B (7.0±0.7 
days). p<0.()l. Mortality and ETI were not significantly diflerent in the 
two groups of patients (0 versus I and versus I. respectively). CON- 
CLUSIONS: Expiration under positive pressure was effective in acutely 
removing secretions in patients with exacerbation of COPD and mild 
acidosis requiring NIPPV. In conclusion, we suggest that this chest 
physiotherapy technique represents a useful therapeutic option for such 
patients and it should often be performed in addition to NIPPV. 

EfTects of Acid-Base Abnormalities on Blood Capacity of Transport- 
ing C()2: Adverse Effect of Metabolic Acidosis — Cavaliere F, 
Antonelli M. Arcangeli A. Conti G. Pennisi MA. Proielti R. Intensive 
Care Med 2002 May;2S(5):6()y-615. 

OBJECTIVE:To investigate the effects of some acid-base abnormalities 
on blood capacity of transporting COj. DESIGN: Prospective study. SET- 
TING: General and Cardiosurgical ICUs of a University 
hospital. PATIENTS: Six groups of ten patients characterized by: 
metabolic alkalosis: respiratory alkalosis; absence of acid-base abnor- 
malities; metabolic acidosis; uncompensated respiratory acidosis; and 
compensated respiratory acidosis. MEASUREMENTS AND RESULTS: 
The CO: dissociation curve. Haldane effect, and the ratio Ra-v between 
Ca-vCOi and Pa-vCOi were calculated from arterial and mixed-venous 
blood gas analyses. The COi dissociation curve was shifted upwards by 
metabolic alkalosis and compensated respiratory acidosis and down- 
wards by metabolic acidosis. The slope of the curve was unaffected, but 
CO: transport not due to Haldane effect was significantly lower in respi- 
ratory acidosis since the slope was less steep at higher Pco, values. In 
comparison with controls, patients affected by metabolic acidosis 
showed lower Haldane effect values ( 0. 1 8±0. 1 5 vs 0.59±0.26 niL of CO: 
per mL of arterial-mixed venous O: content difference; p <0.05) and Ra- 
V values (0.43±0.10 vs 0.84±0.17 mL of CO: transported by 100 mL of 
blood per torr of arterial-mixed venous Pcoi gradient; p <0.05). CON- 
CLUSIONS: Our findings suggest that acid-base abnormalities, particu- 
larly metabolic acidosis, markedly affect blood capacity of transporting 
CO: and may worsen tissue hypercarbia associated with hypoperfusion. 
However, because of possible errors due to small measurements and the 
assumptions of the method, in the future definitive clarification will 
require the construction of original CO; dis.sociation curves for each 
acid-base abnormality. 

Management of Respiratory Failure with Noninvasive Positive Pres- 
sure Ventilation and Heliox .\djunct — Austan F. Polise M Heart Lung 

OBJECTIVE: To investigate the feasibility and the elTicacy of expira- 
tion under positive pressure (PEP mask) as a chest physiotherapy in 
patients with exacerbation of chronic obstructive pulmonary disease 
(COPD) and acute hypercapnic respiratory failure (AHRF) requiring 
non-invasive positive pressure ventilation (NIPPV). DESIGN: A 
prospective, randomised, controlled study. SETTING: A respiratory 
intensive care unit. PATIENTS AND INTERVENTIONS: Twenty- 
seven patients with large amounts of bronchial secretions on clinical 
examination due to exacerbation of COPD and mild acidosis were ran- 
domly divided into two groups. Group A (13 patients) received PEP 
mask plus assisted coughing. The controls (group B. 14 patients) 
received assisted coughing alone. OUTCOME MEASURES: The pri- 
mary end point was to compare total sputum wet weight and to assess the 
feasibility of the PEP mask. Secondary outcomes were; (a) the time 
required for weaning patients from NIPPV. (b) treatment failure 
expressed as mortality within 2 months after discharge from the respira- 
tory intensive care unit (RICU) or the need for endotracheal intubation 
(ETI). RESULTS: The amount of sputum production at the end of phys- 
iotherapy was significantly ( p<().01 ) higher in group A (9.6+3.9 g) com- 

Exhausied by persistent coughing and dyspnea, a 63-year-old man vMth 
chronic obstructive pulmonary disease was admitted to the emergency 
department. Initial treatment included oxygen and pharmacologic and 
noninvasive positive pressure ventilation (NPPV) therapy with minimal 
clinical improvement. In view of this situation, a gas mixture of helium- 
oxygen (heliox) 70%:30% was introduced into the nasal mask as an 
adjunct. Within 20 minutes of therapy, a marked improvement in arterial 
blood gases and a reduction in respiratory rate and accessory muscle use 
was noted. The patient expressed in a high-pitched viiice that he was 
"breathing easier," He remained on NPPV-heliox ;idjunct for SO minutes. 
At the end of this period, the patient was placed on a 50% Venturi oxygen 
mask. He was transferred to the intensive care unit, and 6 days later he 
was discharged from the hospital v^ilh^^ut incident. 

Postoperative Complications: Does Intensive Care Unit Staff Nurs- 
ing Make a Difference? — Dang D. Johantgen ME. Pronovost PJ. 
Jcnckcs MW. Bass EB. Heart Lung 2002 May-Jun;31(3):2l9-228. 

OBJECTIVE: The purpose of this study was to examine the association 


Respiratory Care . September 2002 Vol 47 No 9 


between intensive care unit nurse (ICU) staffing and the likelihood of 
complications for patients undergoing abdominal aortic surgery. 
[)KSIGN: The study is a retrospective review of hospital discharge data 
linked to data on ICU organizational characteristics. Sli TI'INd: Research 
took place in ICUs in non -federal, short-stay hospitals in Maryland. 
PATItNTS: Study included 2(iO(i patients undergomg ahdoniinal aortic 
surgery in Maryland between January \W4 and December iy%. Out- 
come Measures: Outcome measures included cardiac, respiratory, and 
other complications. RESULTS: Cardiac complications occurred in 13% 
of patients, respiratory coinpliealions occurred in .lO'/i , and other compli- 
cations occurred in S'.r of patients. Multiple logistic regression revealed a 
statistically significant increased likelihood of respiratory complications 
(odds ratio |OR|, 2J}: ')5'i confidence interval jCll. I..S()-.^.fi()) in 
abdominal aortic surgery patients cared for in ICUs with low- versus 
high-intensity nurse staffing, an increased likelihood of cardiac complica- 
tions (OR, 1.78: CI, 1.16-2.72) and other complications (OR, 1.74; CI. 
1.15-2.6.^) in ICUs with medium- versus high-intensity nurse staffing, 
after controlling for patient and organizational characteristics. CONCLU- 
SIONS: Within the range of ICU nurse staffing levels present in Mary- 
land hospitals, decreased nurse staffing was significantly associated with 
an increased risk of complications in patients undergoing abdominal aor- 
tic surgery. 

Metabolic Acidosis in the Intensive Care Unit — Gauthier PM. Szerlip 
HM. Crit Care Clin 2002 Apr: 1 8(2 1:289-308, vi. 

Metabolic acidosis is a common occurrence in critically ill patients. 
Understanding the pathological mechanisms underlying the generation of 
protons will enable the clinician to quickly recognize these disorders and 
establish an acceptable treatment strategy. This article presents a logical 
approach to metabolic acidosis. 

Detecting Patients at a High Risk of Developing Chronic Obstructive 
Pulmonary Disease in General Practice: Cross Sectional Find- 
ing Study — Van Schayck CP, Loozen JM. Wagena E, Akkermans RP, 
Wesseling GJ, BMJ 2002 Jun 8:324(7350): 1370. 

OBJECTIVES: To investigate the effectiveness of case finding of 
patients at risk of developing chronic obstructive pulmonary disease, 
whether the method is suitable for use in general practice, how patients 
should be selected, and the time required. DESIGN: Cross sectional 
study. SETTING: Two semirural general practices in the Netherlands. 
Participants: 651 smokers aged 35 to 70 years. MAIN OUTCOME 
MEASURES: Short standardised questionnaire on bronchial symp- 
toms for current smokers, lung function with a spirometer, and the 
quality of the spirometric curve. RESULTS: Of the 201 smokers not 
taking drugs for a pulmonary condition, 169 produced an acceptable 
curve (fulfilling American Thoracic Society criteria). Of these, 30 
{\S'ir. 95'/r confidence interval 12% to 24%) had a forced expiratory 
volume in one second (FEV| ) <80'/t of predicted. When smokers were 
preselected on the basis of chronic cough, the proportion with an FEV| 
<80'7c of predicted increased to 27% (17 of 64: 12% to 38%). Chronic 
cough was a better predictor of airflow obstruction than other symp- 
toms, such as wheeze and dyspnoea. The presence of two symptoms 
was a slightly better predictor than cough only (odds ratio 3.02 ( 1.37 to 
6.64) v 2.50 (1,14 to 5.52)). Age was also a good predictor of obstruc- 
tion: smokers over 60 with cough had a 48% chance of having an 
obstruction. The mean time needed for spirometry was four minutes. 
Detecting one smoker with an FEV| <80% of predicted cost 5 pound 
sterling to 10 pound sterling. CONCLUSIONS: Trained practice assis- 
tants could check all patients who smoke for chronic obstructive pul- 
monary disease at little cost to the practice. Cough and age are the most 
Important predictors of the disease. By testing one smoker a day, an 
average practice could identify one patient at risk a week. 

Effect of a Scoring System and Protocol for Sedation on Duration 
of Patients' Need for \ entilalor .Support In a Surgical Intensive 
Care llnit — Bratlcbo G. Holoss I), Ilaallcii II, Muii AK. Gjerde S, 
PIsek PL. BMJ 2002 Jun 8:324(73.50): 1 386- 1 389. 

PROBLEM: Need lor improved sedation strategy lor adults receiving 
ventilator support. DESIGN: Observational study of effect of introduc- 
tion of guidelines to improve the doctors' and nurses' performance. 
The project was a prospective improvement and was part of a national 
quality improvement collaborative. BACKGROUND AND SETTING: 
A general mixed surgical intensive care unit in a university hospital; 
all doctors and nurses in the unit: all adult patients (>I8 years) treated 
by intermittent positive pressure ventilation for more than 24 hours. 
KEY MEASURES FOR IMPROVliMENT: Reduction in patients' 
mean time on a ventilator and length of stay in intensive care over a 
period of I I months: anonymous reporting of critical incidents; staff 
perceptions of ease and of consequences of changes. STRATEGIES 
FOR CHANGE: Multiple measures (protocol development, educa- 
tional presentations, written guidelines, posters, llyers, emails, per- 
sonal discussions, and continuous feedback) were tested, rapidly 
assessed, and adopted if beneficial. Effects of change: Mean ventilator 
time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) 
from 7.4 days before intervention to 5.3 days after. Mean stay 
decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No 
accidental extubations or other incidents were identified. LESSONS 
LEARNT: Relatively simple changes in .sedation practice had signifi- 
cant effects on length of ventilator support. The change process was 
well received by the staff and increased their interest in identifying 
other areas for improvement. 

Increasing Response Rates to Postal Questionnaires: Systematic 
Review — Edwards P, Roberts 1, Clarke M, DiGuiseppi C, Pratap S, 
WentzR, Kwan I. BMJ 2002 May 18:324(7347): I 183. 

OBJECTIVE: To identify methods to increase to postal ques- 
tionnaires, DESIGN: Systematic review of randomised controlled tri- 
als of any method to infiuence response to postal questionnaires. 
STUDIES REVIEWED: 292 randomised controlled trials including 
258 315 participants INTERVENTION REVIEWED: 75 strategies for 
influencing response to postal questionnaires. MAIN OUTCOME 
MEASURE: The proportion of completed or partially completed ques- 
tionnaires returned. RESULTS: The odds of response were more than 
doubled when a monetary incentive was used (odds ratio 2.02; 95% 
confidence interval 1.79 to 2.27) and almost doubled when incentives 
were not conditional on response (1.71; 1.29 to 2.26). was 
more likely when short questionnaires were used (1.86; 1.55 to 2.24). 
Personalised questionnaires and letters increased response (1.16: 1.06 
to 1.28), as did the use of coloured ink ( 1.39: 1.16 to 1.67). The odds of 
response were more than doubled when the questionnaires were sent 
by recorded delivery (2.21; 1.51 to 3.25) and increased when stamped 
return envelopes were used (1.26; 1.13 to 1.41) and questionnaires 
were sent by first class post (1.12; 1.02 to 1.23). Contacting partici- 
pants before sending questionnaires increased response (1.54; 1.24 to 
1.92), as did follow up contact (1.44; 1,22 to 1,70) and providing non- 
respondents with a second copy of the questionnaire (1,41; 1,02 to 
1.94). Questionnaires designed to be of more interest to participants 
were more likely to be returned (2.44; 1.99 to 3.01 ), but questionnaires 
containing questions of a sensitive nature were less likely to be 
returned (0.92: 0.87 to 0.98). yuestionnaires originating from universi- 
ties were more likely to be returned than were questionnaires from 
other sources, such as commercial organisations (1.31; l.ll to 1.54). 
CONCLUSIONS; Health researchers using postal questionnaires can 
improve the quality of their research by using the strategies shown to 
be effective in this svstematic review. 

Respiratory Care . September 2002 Vol 47 No 9 


Original Contributions 

Clinical Utility of Measures of Breathlessness 

Deborah L Cullen EdD RRT FAARC and Bemadette Rodak MSc CLSpH 

BACKGROlfND: The clinical utility of measures ofdjspnea has been debated in the health care community. 
Although breathlessness can be e\aluated with \arioas iastruments. the most effective dyspnea measurement 
tool for patients with chronic lunj» disease or for measuring treatment effectiveness remains uncertain. 
Understanding the evidence for the validity and reliability of these instruments may provide a basis for 
appropriate clinical application. OBJECTIVE: Evaluate instruments designed to measure breathlessness, 
either as single-symptom or multidimensional instruments, based on psychometrics foundatioas such as 
validity, reliabilitv , and discrintinative and evaluative properties. Classification of each dyspnea measurement 
instrument vvill recommend clinical application in teniis of exercise, benchmarking padents, activities of daily 
living, patient outcomes, clinical trials, and responsiveness to treatment. METHODS: Eleven dyspnea mea- 
surement instruments were selected. Each instrument was assessed as discriminative or evaluative and then 
analyzed as to its psychometric properties and purpose of design. RESULTS: Descriptive data from all 
studies were descril>ed according to their primary patient application (ie, chronic obstructive pulmonary 
disease, asthma, or other patient populations). The Borg Scale and the Visual Analogue Scale are applicable 
to exertion and thus can be applied to any cardiopulmonary patient to determine dyspnea. All other measures 
were detennined appropriate for chronic obstructive pulmonary disease, whereas the Shortness of Breath 
Questionnaire can be applied to cystic fibrosis and lung transplant patients. The most appropriate utilitv for 
all instruments was measuring the effects on activifies of daily living and for benchmarking patient progress. 
Instruments that quantity function and health-related quality of lil'e have great utility for documenting 
outcomes but may be limited as to documenting treatment responsiveness in terms of clinically important 
changes. CONCLUSIONS: The dyspnea measurement instruments we studied meet important standards of 
validity and reliability. Discriminative measures have limited clinical utility and, when nsed for populations 
or conditions for w hich they are not designed or validated, the data collected may not be clinically relevant 
Evaluative measures have greater clinical utility and can be applied for outcome purposes. Measures should 
be applied to the |K>pulations and conditions for which they were designed. Tlie relationship betv\een clinical 
therapies and the measurement of dyspnea as an outcome can develop as respiratory therapists become more 
comfortable with implementing dyspnea measurement instruments and nse the data to improve patient 
treatment Dyspnea evaluation should be considered for all clinical practice guidelines and care pathways. 
Key words: brciilhlcwsucss, dyspnea, Borg Scale. Visual Analogue Scale, O.xygeii Cosi Diagram Baseline/Fransi- 
tion Dyspnea Index BDl, TDl, Chronic Respiratoiy Questionnaire, St George's Respirator)- Questionnaire. SGRQ, 
Sliort)iess of Breath Questionnaire, SOBQ. Breathing Problems Questionnaire. Pulnionaiy Functional .Status and 
Dyspnea Questionnaire, hilnionarv Function Status Scale. |Respir Ciu"e 2(X)2;47(9):986-993| 


Respiratory therapists provide many treatments- to relieve 
shortness of breath, including oxygen therapy and ventilator 
care. Yet current clinical practice guidelines rarely recom- 

Deborah L Cullen EclD RRT FAARC is alTilialed with the Rcspiralorv 
Therapy Priigrani. and Bernadelle Rcidak MSe Cl.SpH is affiliated with 
the Clinical l.ahoratory Science Piiigrarn. Schixil ol Allieil Health Sci- 
ences, School of Medicine. Indiana University. Indianapolis. Indiana. 

mend dyspnea measurement instruments as a means of pa- 
tient evaluation.' The reason for that omission is uncertain. 
Perhaps dyspnea e\ aluation has nt)t been demonstrated to be 

Deborah L Cidlen F.dD RRT F.\.\RC presented a \ersion ol this report 
at the Op[;N Fdrim of the 46th International Respiratory Congress. Cin- 
cinnati. Ohio. October 7-10. 2000. 

Correspondence: Deborah L Cullen FdD RRT FAARC. Respiratory Ther- 
apy Program. School of Medicine. Indiana L'niversily, 1 140 West Mich- 
igan Street. CF 224A. Indianapolis IN 4(i2()2. E-mail: dcullen(n> 


Respiratory Care • September 2002 Vol 47 No 9 


beneficial in today's fast-paced health care environment?- 
Gi\en the emphasis on patient outcdmes in health care, the 
clinical ulilits ol d\spnea measures should be e\|ilored and a 
paradigm for their administration developed. 

During the infancs of inhalation therapN . respiratory treat- 
ments consisted of higii volumes of aerosol and medication 
therapy to soothe mucosa and provide bronchodilation. There 
was limited interest in quantifying breathlessness. and more 
consideration was gi\en to treatment ol breathing difficulties. 
Thai emphasis on treatment continues today. Without em- 
phasis on assessing the patient's inipioxcmcnt in pulmonary 
function and oxygenation, little documentation of treatment 
outcomes is available to clinicians. 

Dyspnea measures ha\ e been used to assess patient re- to exercise. aeti\ ities of daily living (ADL), and 
rehabilitation, and ha\e been included in assessment of 
health-related qualit\ of life.' ■* For example, recent atten- 
tion has been gi\en to dyspnea treatment and assessment 
during mechanical \entilation in the context of patient- 
centered care.'^ "" 

Although many methods are available to evaluate breath- 
lessness, the most effective measure for a specific patient 
condition or treatment remains largely unexplored in the 
respiratory care literature. The American Thoracic Society 
Consensus Guideline on Dyspnea states that dyspnea in- 
struments should be applied as related to the purpose for 
which they were intended.^ That consensus statement pre- 
sents valuable scientific evidence on the mechanisms, as- 
sessment, and management of dyspnea. Additionally the 
statement noted, "inventories that embrace aspects of dys- 
pnea related to quality of life are not yet a routine part of 
the history and physical examination, but ha\e deinon- 
strated a useful role in the clinic and in pulmonary reha- 
bilitation."' Although no specific recommendations were 
forthcoming, the consensus statement does describe dys- 
pnea inventories used for exercise as well as the broader 
context of instruments for dyspnea in regards to quality of 
life.'' It is necessary to differentiate between a breathing 
function and breathing as it affects ADL. One can have the 
ability to breathe and yet not have adequate oxygenation to 
perform ADL such as dressing and climbing stairs. It is 
also possible for a patient to show no change in limited 
objective measures of breathing function and yet to show 
increased ability to cope with ADL. 

Mishoe and MacLean recommend that only those tools 
that have documented sound psychometric properties be 
applied to clinical practice and research. ■* Psychometric 
properties include validity, reliability, and responsiveness, 
among others. Tables 1 and 2 provide definitions of some 
commonly used psychometric terms. 

Important questions include: 

■ How should dyspnea be evaluated? 

• When should evaluation occur? 

• 'Which instrument is most appropriate in a specific 
patient situation? 

• Do different patient conditions require different ui- 

• How do psychometric properties affect the use of these 

The puipose of this study is to evaluate and then to classify 
the clinical utility of measures of breathlessness, either as 
single-symptom or multidimensional instruments, based on 
psychometric foundations such as validity and reliability, as 
well as discriminative or evaluative properties. We make rec- 
ommendations for clinical application of each dyspnea mea- 
sure, in temis of exercise, benchmarking patients, ADL, pa- 
tient outcomes, clinical trials, and response to treatment. 
Evaluation of each dyspnea measure analyzed can guide as- 
sessment of patient progress, treatment effectiveness, and 
short-term or long-term therapy goals. Tliis template will 
assist respiratory clinicians to identify the best measures for 
clinical practice guideline inclusion or clinical application. 

Why Measure Patient Outcomes? 

Outcomes are important indicators of patient progress and 
assist in evaluating the patient.** Clinicians have traditionally 
assessed objective physiologic variables such as oxygenation 
or lung function with mechanical instruments. Another form 
of instrumentation, the questionnaire, is more patient-cen- 
tered and evaluates function and ADL in relation to quality of 
life, which can quantify both short-temi and long-term pa- 
tient progress. Various types of measures are used to appraise 
patient outcome status, including general health status mea- 
sures, disease-specific indices, functional status measures, and 
symptom evaluation.-'-^'* General health surveys, such as 
health-related quality of life measures, assess changes in phys- 
ical, social, and emotional well being because of illness and 
are useful measures of long-term outcoines.'' Commonly used 
general health status measures are the Medical Outcome Study 
Short Form 36. the Sickness Impact Profile, and the Quality 
of Well-Being Index. Disease-specific measures were devel- 
oped as more sensitive indicators became necessary for cer- 
tain conditions, such as arthritis, asthma, and diabetes. Both 
disease-specific and general health status instruments evalu- 
ate the impact of a condition on the patient's quality of life 
and therefore assist in determining treatment effectiveness 
and efficacy.-'*'* Because disease-specific measures evaluate 
particular patient characteristics and function related to a con- 
dition, those results document the patient's progress.-"^'' In- 
tegrating patient outcomes into clinical practice guidelines, 
cardiopulmonary pathways, and rehabilitation plans is pri- 
mary to disease management and managed care. 

Functional status can be determined via a wide variety 
of measures. A functional assessment may target the pa- 
tient's independence in a variety of activities or indicate 

Respiratory Care • September 2002 'Voi, 47 No 9 


Clinical Utility of Measures of Breathlessnbss 

Table I. Psychometric ami McasureniciU Qualily Terms 




Categorical variable 
Ceiling/floor effect 
Clinical utility 
Continuous variable 



Internal consistency 



Minimum clinically imponant response 




Ratio properties/ratio measurements 







Health status measure that is tied to an external measure. Procedure used to establish extreme response 

position on attitude scales. 

Standard for comparison; a valid and reliable measure 
Variable in which properties differ in kind, not degree 

Inability of an instrument to demonstrate improvement/inability of an instrument to demonstrate deterioration 
Usefulness in terms of patient assessment 
Variable in which properties differ in degree, not in kind 
Describes a measure (of dyspnea) that differentiates between people, based on whether the individual has 

mild, moderate, or severe dyspnea. Capable of measuring individual differences. 
Describes a measure that can determine how much change has occurred within 1 patient, represented as 

trivial, small but important, moderate, or large improvement/deterioration in dyspnea 
Describes a measure applicable to multiple situations, not strictly adapted to 1 environment 
Extent to which items correlate among themselves 
Describes results from different patients 
Describes results from the same patient 

An established threshold that represents a clinically important measured response 
Observable measurable result 

Pattern, guideline, standard, prototype, pathway, model, or example 

Quantitative and qualitative measurement of psychological functioning, states, traits, processes, and changes 
A scale having equal intervals and an absolute (true) zero 
Extent to which a measure is reproducible (see Table 2) 
Sensitivity to change in a measurement as a result of treatment or time 
Associates qualitative constructs with quantitative metric units 
The ability of an instrument to accurately determine when a condition is present; that is, the instrument's 

accuracy in providing true positive results 
The ability of an instrument to accurately determine when a condition is not present; that is, the instrument's 

accuracy in providing true negative results 
Ability of an instrument to measure what one intends to measure. Common types of validity include content, 

criterion, and construct validity (see Table 2). 

l.^dapk'd Iron Relerences 1(1 and 49 ) 

the level of shortness of breath and its effect on emotional 
functioning."*'' By quantifying a patient's functional abil- 
ities, a measure can specifically evaluate the effectiveness 
of medication, treatment, and therapy. Measures of breath- 
lessness can assess the impact of shortness of breath on 
patient function. Since respiratory clinicians provide ther- 
apies for patients experiencing shortness of breath, clini- 
cians should be familiar with the cadre of coinmon dys- 
pnea measures in order to select the best instrument for a 
given clinical or research situation. 

How Appropriate Are Dy.spnea Measures? 

Dyspnea instruments were developed to evaluate short- 
ness of breath under various conditions and circumstances. 
Some were developed to assess exercise-induced dyspnea, 
whereas others determine dyspnea related to ADL,''-' Each 
measure is limited by its purpose and design. ■'■^ Because 
the initial purpose ol each instrument is key to its appli- 

cation, clinicians should differentiate among the instru- 
ments for the best application. 

A brief explanation of some psychometric terms may be 
helpful in understanding the importance of selecting ap- 
propriate instrumentation for specific populations. 

The validity of an instrument is the degree to which it 
measures what it is designed to measure; that is, can the 
interpretation of its scores be justified''-* Validity is not 
established for all settings; it must be verified for each 
specific setting and population. For example, a measure 
validated to quantify exercise-induced dyspnea may not be 
appropriate to quantify dyspnea related to congesti\e heart 
failure or bronchospasm. 

Reliability refers to the reproducibility of a measure- 
ment; that is. if the same instrument is administered twice 
to the same population at different times or by different 
raters, would the results be the same? 

An instrument is disciiiniuaiive if the measurements 
differentiate between patients; that is. can it measure in- 


Respiratory Care • September 2002 Vol 47 No 9 

CiiNicAi U 111 11^ oi Measures of Breathlessness 

Table 2. Validity and Reliabililv Terms 



Concurrent validity 
Construct validity 

Content validity 
Criterion validity 

Inter-rater/inter-observer reliability 
Intra-rater/intra-observer reliability 

Inter-case correlation 
Internal consistency 


(Adapted from References 10 and 49) 

Relationship between 2 instruments designed to measure the same concept/construct 

Validity of measures that assume that the concepts of interest are embedded in theory. For instance, changes 

in dyspnea should correlate with differences in external criteria such as forced expiratory volume in the 

first second (FEV,) 
Extent to which itemized content corresponds with objectives 

Extent to which a measure of interest correlates with an established, accepted reference standard 
Extent to which 2 or more independent observers agree in their measurement of a variable 
Extent to which one observer's initial measurement agrees with his or her subsequent measurements of the 

same variable 
Between-case correlation ol measures 
Extent to which an individual responds consistently to the items in a psychometric instrument; that is. how 

consistently the test measures the intended variables 
Same test is given to same individual after a period of time elapses 

dividual differences between those who have a certain 
condition and those who do not? An evaluative instrument 
determines change within an individual patient, for exam- 
ple a change in an individuaKs health status. 

Psychometric properties, or statistical makeup of the 
instrument, remain the cornerstone of clinical application 
for each instrument.'" Researchers validate each instru- 
ment differently because each measure is intended for a 
specific purpose." Consider that the 0-10 Borg Scale ini- 
tiallv measured psychophysical properties with 12 women 
on bicycle ergometers at various workloads and that later 
the same measurement was performed with 32 high school 
boys.'-" Heart rates were correlated with exertion to de- 
termine if the instrument was valid, thereby demonstrating 
a relationship with an accepted standard.'-" When the 
subjects were retested under similar conditions the reli- 
ability of the instrument was established. 

The process used to establish properties for the Borg 
Scale was very different from that used for the St George's 
Respiratory Questionnaire (SGRQ). Tests of the SGRQ 
used a majority of male patients to validate the instru- 
ment's 52 items and 3 domains. I of which is dyspnea- 

Given that context, various instruments have been de- 
signed for the quantification of breathlessness but were 
tested in specific patient populations under expressed cir- 
cumstances. Instrument validation is a continuing process. 
Over time, researchers and clinicians have examined the 
relationship of dyspnea inventories to other patient popu- 
lations and different clinical conditions, as well as to each 
other. Validity becomes a key concern when an instrument 
is applied to other populations and settings than those for 
which it was originally developed. The popular Borg Scale 
was later examined for validity and reliability for chronic 
obstructive pulmonary disease (COPD) patients and even- 

tually correlated to the Visual Analogue Scale (VAS).''^"' 
Thus the usefulness of the Borg Scale was expanded. 

The appropriate application or clinical utility of a mea- 
sure must be grounded in the scientific evidence of valid- 
ity, reliability, evaluative and discriminative properties, 
and generalizability. Consider, for example, using the Borg 
Scale or SGRQ with a ventilator-dependent patient. These 
instruments may yield data, but the dyspnea score may 
have limited meaning, since the measure has not been 
validated for the ventilator population. Consequently, re- 
spiratory clinicians should apply popular dyspnea mea- 
sures judiciously, as the data generated may lack clinical 
relevance. Eakin et al perhaps best explained this concept; 
■"Given the complexity of this symptom | shortness of breath] 
and the various approaches to measurement, the choice of 
dyspnea measures should be based on information about 
their reliability and validity."'^ 

Initial Development of Dy.spnea Inventories 

Since perceived difficulty with breathing is typically a 
patient's motivation in seeking medical care, dyspnea mea- 
sures were initially developed (in the 1950s and 1960s) to 
examine lung function and breathing ability. Among these 
was a 5-point scale by Fletcher, which graded levels of 
dyspnea.'** This tool was further refined into a measure 
applied to chronic bronchitis and emphysema patients, 
called the Medical Research Council Breathlessness Scale 
(MRC).''' Aitken developed the VAS in 1969 for "mea- 
surement of feelings."-" Initially, the 10 cm anchor-ended 
vertical (or horizontal) line was used to quantify pain, 
then, later, shortness of breath.-' The patient is requested 
to mark on the line at the point that best describes his or 
her breathlessness. The position of the mark relative to the 
zero point bottom anchor of the scale is then recorded. 

Respiratory Care • September 2002 'Vol 47 No 9 


Clinical Utility of Measures of Breathlessness 

In 1970 Dr Gunnar Boig invented a 6-20 point scale to 
measure perceived exertion. He later modified this to a 
0-10+ scale.'- This newer measure was recognized as 
psychometrically superior, with ratio properties and non- 
linear spacing of the descriptors, i"" Since this instrument 
was based on psychophysical principles, it was applied to 
perceived breathlessness as well as to exertion. Although 
these same scales are in use today, they ha\e been joined 
by multidimensional instruments that relate dyspnea to 
various domains, such as ADL and quality of life." Table 
3 lists and describes the measures of breathlessness. 


The dyspnea measurement instruments selected for eval- 
uation of clinical utility were the Borg Scale,'-" '^-- the 
VAS,2o-2i-25-25 the Oxygen Cost Diagram.^''-'' the 
^^f^C 18.19.28-30 (i^g Baseline/Transition Dyspnea Index 
(BDI/TDI),-*'" the Chronic Respiratory Questionnaire 
dyspnea component (CRQ), '■'-"' the SGRQ activity com- 
ponent,'^" the Shortness of Breath Questionnaire 
(SOBQ).'^ the Breathing Problems Questionnaire,-''^ the 
Pulmonary Functional Status and Dyspnea Questionnaire,'''' 
and the Pulmonary Function Status Scale. ■"'-" Data con- 
sisted of initial and corollary research regarding the psy- 
chometric properties and subsequent related studies of the 
properties of the questionnaires. ■'-■■'* An initial analysis of 
each measure included classification as either discrimina- 
tive or evaluative. ■*''''''^ If the instrument was discrimina- 
tive, we analyzed its psychometric properties, use among 
populations, medical conditions, interpretability and gen- 
eralizability.""' If an instrument was evaluative, we ana- 
lyzed its psychometric properties, inteipretability. respon- 
siveness, sensitivity, common applications, and 
generalizability. ■'''■""* After analysis of the research related 
to each questionnaire was completed, descriptive results 
were categorized into clinical rubrics of exercise, ADL, 
benchmark, outcomes, responsi\eness. and clinical trials, 
representative of hierarchical utility. 


All measures were valid in the populations in which 
they were tested, although this validity varied as to the 
degree and type. Additionally, all measures demonstrated 
test-retest reliability. Moreover, the BDI/TDI and CRQ 
demonstrated inter-rater and intra-ratcr reliability, whereas 
the SGRQ had inicr-case reliability (Tables 3 and 4). Dis- 
criminative measures included the Borg Scale. VAS. Oxy- 
gen Cost Diagram, MRC, and BDI. Evaluative measures 
were the TDl. SGRQ, CRQ, SOBQ, Breathing Problems 
Questionnaire, Pulmonary Functional Status and Dyspnea 
Questionnaire, and Pulmonary Function Status Scale. Men- 
tal, physical, and social functioning were the primary foci 

of the Pulmonary Functional Status and Dyspnea Ques- 
tionnaire and the Pulmonary Function Status Scale. ADL 
was the principle focus of the SOBQ and the Breathing 
Problems Questionnaire. 

Each study was described according to its primary ap- 
plication (eg, COPD. asthma, or other patient populations). 
The Borg Scale and VAS are applicable to exertion and 
hence can be applied to any cardiopulmonary patient to 
determine dyspnea. All other measures were determined 
appropriate for COPD. The SOBQ can be applied to cystic 
fibrosis and lung transplant patients. The most appropriate 
utility for all measures was for ADL and for benchmarking 
patient progress. Measures quantifying function and health- 
related quality of life have great usefulness for document- 
ing patient-centered outcomes but may be limited for doc- 
umenting treatment response in terms of clinically 
impintant changes. 


Although all measures exhibited validity for the popu- 
lations studied, the primary population of these studies 
was pulmonary patients, specifically COPD. Several mea- 
sures were validated in terms of construct validity, cone- 
lating changes in dyspnea with other criteria, such as lung 
function or walking distance. The validation of dyspnea 
measures strengthens their usefulness and encourages their 
application. Measures can be tested with various popula- 
tions, such as lung transplant or cystic fibrosis, as well as 
under multiple conditions, such as drug regimens. Mahler 
explains this principle: ". . . the demonstration of validity 
is a continuing process that requires continual evaluation 
and testing.""^" Reliability criteria are typically satisfied 
with repeated measures; that is, test-retest measures. How- 
ever, for interviewer-administered measures such as the 
BDI/TDI and CRQ, inter-rater and intra-rater consistency 
standards must be met. All the dyspnea measures studied 
satisfied reliability standards. 

Although validity and reliabiliiv standards were met. the 
clinical usefulness of the instruments differed. Discrimi- 
native instruments are limited b\ design because they only 
permit between-patient comparisons. The Borg Scale and 
VAS, with their one-item formats, were designed for mea- 
surement during exercise and can best be used for exertion 
measurement and to benchmark exertion dyspnea. 

The Oxygen Cost Diagram and the MRC are discrimi- 
native measures that collect patient data that are quantified 
and interpreted as comparisons for .ADL as well as be- 
tween-patient benchmarks. In contrast, the ev aluative mea- 
sures are more descriptive, with increased clinical utility 
permitting evaluation over time of ADL. benchmarking, 
outcome comparison, quality of life, sensitiv ity to change, 
and clinical trials (see Table 4). New research into patient 
response and clinically important changes permits assess- 


Respiratory Care • September 2002 Vol 47 No 9 

Clinical Liniirv oi Measures of Breathlessness 

Tabic 3. Dyspnea Measurement Insirumeiils 



Borg scale 0-10 scale with nonlinear spacing; allows for scores > 10. 
= no dyspnea at all. 10+ = maximal dyspnea. 

Psychometric Properties: Scaling, Validity. Reliability 

Categorical scaling with ratio properties. Content/criterion validity. 
Test-retest aMiabilily. Can discriminate between patients' perceived 
shortness of breath. 

VAS Horizontal or \ertical 100 mm line with descripli\e anchors at 

the ends 
Bottom anchor = No breathlessness 
Top anchor = Greatest breathlessness 
LIsuallv self-admimstered but can be interviewer-administered 

Continuous scaling. Construct/criterion valdity. Test-retest and 
inter-rater/intra-raler reliability. Can discriminate helween 
patients' perceived shortness of brcMlh, 

OCD 10 cm line along which activities arc designated, corresponding 

lo metabolic equivalents of activities, from sleeping to brisk 
uphill walking. Patient indicates the point above which 
dyspnea would not let him or her go. 

Continuous scaling on vertical line. Content/criterion validity. 
Test-retest reliability. Can discriminate between patients' 
perceived shortness of breath. Characterizes COPD. 

MRC .'S-point scale quantifying breathlessness in grades from 1 to 5. 

with grades 1 and 2 being activities that provoke dyspnea {hill 
walking) and 5 being severe impairment (shortness of breath 
with dressing). Can be self-scored but is usually interviewer- 

Categorical scaling. Content/crilcrion/construct validity. Test- 
retest reliability. Can discriminate between patients' perceived 
shortness of breath. Historically used to characterize 
populations. Characterizes COPD. 

BDIATDl Interviewer scored 0-12 lor BDl related to magnitude of work, 

activities, effort related to shortness of breath. TDI evaluates 
changes and is scored -9 to +9. 

Categorical scaling. Contcnt/criterion/construct validity. Test- 
retest and inter-rater/intra-rater reliability for characterizing 
COPD. BDl is discrimuiativc for criteria at I point in time, 
whereas TDI evaluates change from baseline state. 

CRQ Developed for COPD HRQL. Consists of 4 domains: dyspnea, 

fatigue, mastery, emotion. Patient selects dyspnea-related 
activities and each is scored 1-7 for severity. Interviewer must 
be skilled to administer to patients with chronic lung disease. 

Categorical scaling. Content/criterion validity. Test-retest, internal 
consistency and inter-rater/intra-rater reliability. Evaluative for 
all domains. 

SGRQ Each activity is related to dyspnea, and questions are weighted. 

obtaining scores for 76 items. Measures HRQl- in .3 domains: 
symptoms, activity, impacts. Self-administered for patients 
with chronic luns disease. 

Categorical scaling. Content/criterion validity. Test-retest 
reliability and inter-case correlation. Evaluative for all 3 

SOBQ Self-reported 24-item ADL-related shortness of breath 

questionnaire for COPD. cystic fibrosis, and lung transplant 
patients undergoing pulmonary rehabilitation. 

Categorical scaling. Content/construct validity. Internal 

BPO COPD/chronic bronchitis HRQL. 33 items and 13 domains: 

walking, bending, bathing, house chores, social interactions, 
weather effects, fume effects, colds, sleep, medicine, dysphoric 
states, eating, excretion. 27 items for "problem score." 

Categorical scaling. Content/construct validity. Test/retest 
reliability. Based on psychological constructs. Evaluative 
instrument constnicled for clinical trials. 

PFSDQ Developed to measure impact on daily performance. Self- 

administered. 164-item. intensity-related, for ADLs for COPD. 
Evaluates 79 functions as well as dyspnea. 

PFSS 35 self-administered questions related to ADL. mental, physical, 

and social functioning. Developed to measure impact on daily 
performance with COPD patients. 

V.AS - Visual Analogue Scale 

(K-'U ^ Oxygen Cost Diagram 

COPD = chronic otislmclivc pulmonary disease 

MRC - Medical Research Council Brealhlessnes.s Scale 

BDI/TDl = Baseline Dyspnea Indes/Transilion Dyspnea Index 

CRQ = Chronic Respiratory Qucslionnaire 

HRQL = heallh-relaled quality of life 

Categorical scaling. Content/construct validity. Internal 
consistency reliability. Evaluative instrument. 

Categorical scaling. Content/construct validity. Test-retest 
reliability. Evaluative and sensitive to longitudinal change. 

SGRQ/Dyspnea = Si George's Respiratory QucMionnaire 

SOBQ = Shortness of Breath Queslionnaire 

ADL = activities of daily living 

BPQ - Breathing Prohlcms Queslionnaire 

PFSDQ ~ Pulmonary Function Status and Dyspnea Questionnaire 

PFSS = Pulmonary Function Status Scale 

Respiratory Care • September 2002 Voi 47 No 9 


Clinical Utility of Measures of' Breathlessness 

Table 4. Clinical LUililv 








Borg scale 













ADL = activiiies of daily living 

VAS = Visual Analogue Scale 

OCD = Oxygen Cosl Diagram 

MRC = Medical Research Council Breathlessness Scale 

BDIATDI = Baseline Dyspnea Index/Transition Dyspnea Index 

SGRQ/Dyspnea = Si George's Respiratory Questionnaire 

CRQ - Chronic Respiralor\' Questionnaire 

SOBQ = Shonness of Breath Questionnaire 

BPQ = Breathing Problems Questionnaire 

PFSDQ - Pulmonary Function Status and Dyspnea Questionnaire 

PFSS - Pulmonary Function Status Scale 


ment of a treatment's impact and the instrument's ability 
to detect changes in dyspnea. Treatment effectiveness can 
be determined by clinically important changes identified with 
dyspnea measures such as the CRQ. This is an important 
concept as respiratory therapists strive to strengthen evidence 
related to clinical treatments and disease management. 


The dyspnea measures examined meet important stan- 
dards of validity and reliability. Discriminative measures 
have limited clinical utility, and when used with popula- 
tions or in conditions for which they are not designed nor 
validated, the data collected may not be clinically relevant. 
Evaluative measures have greater clinical utility and can 
be applied for outcome purposes. Measures should be ap- 
plied as designed: for example, clinical practice guidelines 
typically reference the Borg Scale or the VAS and make 
no recommendations regarding other instruments. In the 
future, clinical practice guidelines may consider referenc- 
ing other measures as appropriate. 

Measures of breathlessness should continue to be vali- 
dated under various conditions and with nuiltiple popula- 
tions. Moreover, it may prove valuable to incorporate these 
measures into clinical practice guidelines and disease path- 
ways as assessment tools. The relationship between clin- 
ical therapies and the measurement of dyspnea as an out- 
come can develop as respiratory therapists become more 
comfortable with implementing these measures and using the 

data to improve patient treatment. Measures of breathlessness 
may provide evidence of clinically important change as a 
response to treatment and disease management. 


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48. de Torres JP. Pinto-Plata V. Ingenito E, Bagley P, Gray A. Bergcr R, 
Celli B. Power of outcome measures to detect clinically significant 
changes in pulmonary rehabilitation patients w ilh COPD. Chest 2(X)2; 
121(4): 1092-1098. 

49. Mahler DA. Dyspnea. New "I'ork: Marcel Dekker: 1998:158, 

Respir.atory Carl • September 2002 Vol 47 No 9 


Relationship of Neonatal Endotracheal Tube Size 
and Airway Resistance 

Melisa J Oca MD, Michael A Becker RRT, Ronald E Dechert RRT, and Steven M Donn MD 

BACKGROUND: Infants receiving mechanical ventilation require narrow-lumen, small-diameter 
endotracheal tubes. OBJFX'TIVK: Compare the resistances of endotracheal tubes used in the 
neonatal intensive care unit. METHODS: Endotracheal tubes of internal diameter 2.5, 3.0, 3.5, and 
4.0 mm were tested with a standard neonatal ventilatctr and a test lung. An endotracheal tube of 
each diameter was cut to 12 cm and connected to a flow transducer at one end and the test lung at 
the other. Serial measurements of resistance were made at various flows (6, 8, 10, and 12 L/min) and 
ventilator rates (30-90 breaths/min) encompassing the ranges of clinical practice. Analysis of 
variance was performed for each tube size, comparing resistance to flows and ventilator rates. 
RESULTS: Resistance was significantly higher with the 2.5 mm tube than with the others. There 
was also a consistent trend, in all the tube sizes, towards higher resistance as flow was increased. 
CONCLUSIONS: The higher resistance of the 2.5 mm tube may be detrimental to extremely low 
birthweight infants kept on mechanical support merely "to grow." The higher resistance may 
increase the work of breathing and thus increase caloric expenditure and impede growth. Key 
words: neonatal, encloiraclieal tube, ainvay resistance, mechanical venlilation. ventilator. [Respir Care 


A number of factors contribute to the determination of 
airway resistance, including the air flow velocity, the length 
of the conducting tubes, the properties of the gas, and most 
importantly, the diameter of the airway. According to Poi- 
seuille"s law, resistance is inversely proportional to the 
fourth power of the radius. Thus, small changes in airway 

At ttic time of this research Melisa J Oca MD was affiliated with the 
Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Uni- 
versity of Michigan Health System. Ann .Arbor. Michigan. She is now 
afniiated w ith the Department of Pediatrics. William Beaumont Hospital. 
Royal Oak, Michigan. Steven M Donn MD is affiliated with the Depart- 
ment of Pediatrics, Division of Neonatal-Perinatal Medicine, and Mi- 
chael A Becker RRT and Ronald H Declicrt RRT are affiliated with the 
Department of Critical Care Support Services. University of Michigan 
Health System. Ann Arhor. Michigan. 

Melisa J Oca MD and Steven M Donn MD presented a version of this 
repon at the annual meeting of the Pediatric Academic Societies, San 
Francisco, California. May 1. 19'W. 

Steven M Donn MD has served as a consultant to Thermo Respiratory 
Group (now VIASYS Healthcare), Palm Springs, California. 

Correspondence: Steven M Donn MD. Motl Children's Hospital. 1500 E 
Medical Center Drive. F.'iV'JO CS, Ann Arhor Ml 4S10y-02.=:4. F.-mail: 

diameter can have a profound effect on airway resistance. 
In vivo studies have demonstrated that the resistance of the 
respiratory system and diaphragmatic activity falls by 30- 
4()7f when ventilated infants are e.xtubated.' It has also 
been shown that resistance is considerably higher when 
continuous ptisitive airway pressure (CPAP) is applied 
through an endotracheal tube (ETT) than when applied 
through a chamber.- Air flow resistances and respiratory 
mechanics of ETTs have been studied in \itro,'-^ and all 
the studies indicate that the smaller the diameter of the 
ETT the higher is its resistance. 

The development of microprocessor-based flow sensor 
technology for neonatal intensive care has enabled easy 
measurement of airway pressure, flow, and \i)lume, on a 
breath-to-breath basis. ''-^ The present study was designed 
to measure the resistance of ETTs comtiionly used in clin- 
ical practice and the effects on resistance of \aiy ing flow 
and mechanical \entilator rate. 


Stand;ird neonatal ETTs (Tyco Healthcare/Mallinckrodt, 
St Louis, Missouri) with internal diameters of 2..'>. .^.0, .^..S, 
and 4.0 mm were used. Each tube was cut to 12 cm. The 
proximal end of the tube was connected to the How sensor of 
an infant/peiliatric ventilator (VIP BIRD, VIASYS Health- 
care/Bird Products Coiporation, Palm Springs, California). 


Rfspir \TOR^• Care • September 2002 Vol 47 No 9 

Relationship oi- Ni-Onatai. ENnoTRAciiF.Ai, Tube Sizi; and Airway Ri-sistance 

Table I . ResislancL' of Various F.ndolrachcal Tube Sizes* 

Resjslance (cm H,0/L/s)t 




30 brcalhs/niin 
= 20 cm H,() 

1 ^ 60 ha\iths/min 
PIP = 20 cm H.O 

r = •■X) ha'aths/mm 
PIP - 20cm ll.O 

1 -- 30 hrcaths/min 
PIP 25cmH,0 

1 " 60 hrcallis/min 
PIP = 25 cm H,0 

f = ')0 brealh-ymin 
PIP = 25 cm ILO 

(cm ll.CViys) 

2.5 mm 


6 lymin 








8 Uinin 








10 L/niin 












3.0 mm 






6 L/niin 
















10 IVmin 








12 lyniin 




3.5 mm 






6 L/min 
















10 IVmin 








i: IVmin 




4.0 mm 






6 L/min 








8 L/min 








10 IVmin 










; dianielcr. 







•Tube si/cs , 

Lire insidi 

tThc rcMslancc value 

s are averages i>t M^ 

consecutive brcalhs. 

f = mechanical respiratory rale 
PIP = peak inspiralory pressure 
ETT = ciidoiracheal lube 

The distal end was attached to a lung model (Neonatal Dem- 
onsUation Lung Model. IngMar Medical, Pittsburgh. Penn- 
sylvania). Compliance was set at 0.8 mL/cm H-,0. 

The ventilator was set in the time-cycled, pressure-lim- 
ited, intermittent mandatory ventilation mode. Inspiratory 
time was fixed at 0.4 second, peak inspiratory pressure 
(PIP) was held constant at 20 cm H^O, and positive end- 
expiratory pressure was kept constant at 4.0 cm HjO. For 
each tube size, serial measureinents of resistance were 
made at flows of 6, 8, 10, and 12 L/min and at mechanical 
breath rates of 30, 60, and 90 breaths/min. which are the 
most common ranges used in clinical practice. A second 
.series of measurements was also made under the same set 
of conditions, except that PIP was increased to 25 cm H^O. 

Measurements were made using a voluine monitor (BIRD 
Partner Hi) and the neonatal sensor. A 30-breath average 
was used at each study point. Data were subjected to anal- 
ysis of variance and were deemed statistically significant 
if p < 0.05. 


Table I shows the resistance of each ETT size at each of 
the flows and rates studied. For each tube size there was a 

nonsignificant trend toward increased resistance as flow 
and PIP were increased. Increasing the rate also had little 
impact. There were slight, nonsignificant increases in re- 
sistance when PIP was increased from 20 cm H^O to 25 
cm HsO. Because none of those changes were statistically 
significant wiiliin the nieasiireiucnts for each size tube, all 
of the resistance measurements for a given tube size were 
aggregated. Figure 1 shows the relationship between flow 
and resistance for each tube size. The average resistance of 
the 2.5 mm ETT was significantly higher than any of the 
others (p < 0.001 by Dunnet's post-hoc analysis).** Dif- 
terences among the 3.0, 3.5, and 4.0 mm ETTs were not 
statistically significant. Table 2 compares the data from 
the 2.5 mm ETT to each of the other ETTs. 


This study demonsiratcs thai resistance is significantly 
higher with a 2.5 mm ETT than with a 3.0. 3.5. or 4.0 mm 
ETT. under identical test conditions. The differences in 
resistance ranged from l^/r to 24'/f . Changes in gas flow. 
mechanical ventilator rate, or PIP had little or no impact. 

Re.spir.atorv Care • September 2002 Voi 47 No 9 


Relationship of Neonatal Endotracheal Tl'be Size and Airway Resistance 


^ 500 





I 400 







Flow (n = 6) 

I 1 6 L/min 
[13 10 L/min 
12 L/min 

2.5 3.0 3.5 

Internal Diameter of ETT (mm) 


Fig. 1 . Relationship between endotracheal tube (ETT) size (Internal diameter) and resistance. For each tube size, measurements were made 
at 6, 8, 10, and 12 L7min. Resistance was significantly higher with the 2.5 mm tube than with the 3.0, 3.5, or 4.0 mm tubes. For each tube 
size there was a trend toward increased resistance as flow was increased. 

Table 2. Dunnet's Post-Hoc AiKilysis" Comparing Endotracheal Tube Resistances 

ETT Inner Diameter (mm) Mean Difference Standard Error 


95% CI 



3.0 vs 2.5 
3.5 vs 2.5 
4.0 vs 2.5 



< 0.00 1 





ETT - endotracheal lube 

•The mean difference is significanl when p •-- 0,05- 

An important but unresolved issue in neonatology is 
when to e\ttibate the extremely low birthweight (ELBW) 
intanl who requires minimal venlilalory suppiirt. Onesehool 
of thought suggests the continued use of assisted ventila- 
tion to decrease the work of breathing (WOB), minimize 
caloric expenditure, and enhance grt)wth. On the other 
hand. LeSouef et al have shown that resistance and WOB 
(as assessed by diaphragmatic electromyography) decrease 
after extubation.' In \ilro studies measuring WOB in a 
mechanical lung model demonstrated a significant decrease 
in WOB when the inner cannula of a tracheostomy tube 
was removed.'' The significantly higher resistance associ- 
ated with the 2..'S mm tube implies that the ELBW infant 
may have to work harder lor require more ventilatory sup- 
port) with the 2.5 mm ETT than with a larger one. This 

impedes ventilator weaning and may increase mechanical 
barotrauma and further contribute to the de\ek)pment of 
chronic lung disease. 

In their 1987 survey of 8 neonatal intensi\e care units. 
Avery et al identified a neonatal intensi\e care unit that 
used early application of nasal CP.4P. w hich they found 
was associated with a significantly lower incidence of chronic 
lung disease and higher sur\i\al rate.'" Tliis early CPAP 
inter\ention has been described in the literature, mostly 
through retrospective reports,""'- and randomized controlled 
trials are certainly wananted. Howe\er. one cannot argue the 
invasive nature of endoUacheal tubes and mechanical venti- 
lation and their contributions to chronic lung 

The results of the present report should be inteipreted 
cautiously. First, the study was accomplished using a test 


Respiratory Care • September 2002 Vol 47 No 9 

Relationshii' oi Ni-:onatal Endotrachhai Tube Size and Airway Resistance 

lung, with the compliance set to nearly normal, and our 
model cannot take into account the varying physiology ot 
an ELBW infant, including rapidly changing chest wall 
compliance, \ariable respiratory effort, and an unstable 
airway. Wright et al showed that in vivo ETT resistances 
of patients with acute respiratory distress syndrome were 
significantly higher than in vitro resistances."^ Thus an in- 
fant undergoing mechanical ventilation for respiratory fail- 
ure may have significantly higher airway resistance than 
was observed in the present in vitro study, because of 
increased secretions, a kinked ETT. or varying head posi- 
tion. Second, the present study did not examine the effect 
of varying the ETT length. For the purpose of creating 
identical scenarios, each tube was cut to a standard length, 
in clinical practice, the 2.5 mm ETT would probably be 
cut to a slightly shorter length to accommodate the smaller 
patient who requires it. thus slightly decreasing resistance. 
It was somewhat surprising that there were no signifi- 
cant differences in resistance among the 3.0, 3.5, and 4.0 
mm ETTs. One would presume a difference based on Poi- 
seuille's law alone. We were intrigued by this finding and 
repeated the study using much higher flows. Indeed, when 
the flows exceeded 18 L/min there was a linear relation- 
ship, with the largest tube exhibiting the least resistance. 
However, those higher flows are well beyond what is used 
in clinical practice. 


If a 2.5 mm ETT is necessary for initial ventilatory 
support of an ELBW infant, consideration should be given 
to placing a larger tube at the appropriate point in clinical 
management, to avoid the higher imposed WOE associ- 
ated w ith the 2.5 mm ETT. Placement of a larger tube is 
not without hazards, as there is a relationship between 
larger ETT diameter and the incidence of subglottic ste- 
nosis.' ' '^ Alternati\ely. earlier extubation or avoiding in- 
tubation v\ ith the early use of CPAP may also be beneficial 
and prevent the infant from having to "breathe through a 


1. LcSouef PN. Enghmd SJ. Bryan AC. Total resistance of ihc respi- 
ratory system in prelerni inlanis with and wilhoul an endotracheal 
liihe. J Pedialr I W4:1()4| 1 i:l()S 1 1 I , 

2. Gregory GA. Killcrrnan JA. Phihhs RH, Tooley WH, Haruillon WK. 
Trealmeni ol idiopathic respiratory distress syndrome with continu- 
ous positive airway pressure. N Engl J Med iy7l;2S4(24):l33.1- 

.3. Sullivan M. Paliotia J. Saklad M. Endotracheal tube as a factor in 
measurement of respiratory mechanics. J AppI Physiol I976;4I(4): 

4. Souihgate MT. Airflow resistances of endotracheal luhes (editorial). 
JAMA 1977:2.^7(1.^1: 1. "!fi2. 

."i. Wright PE. Marini JJ. Bernard GR. In vitro versus in vivo compar- 
ison of endotracheal tube airflow resistance. Am Rev Respir Dis 
1989(1): 1 40: 10- 16. 

6. DeVreis DF. Baker L. Basic engineering concepts of pulmonary 
graphics. In: Donn SM. editor. Neonatal and pediatric pulmonary 
graphics: principles and clinical applications. Armonk NY: Futura; 

7. Bhutan! VK. Sivieri EM. Physiological principles for bedside as- 
sessment of pulmonary graphics. In: Donn SM. editor. Neonatal and 
pediatric pulmonary graphics: principles and clinical applications. 
Armonk NY: Futura; 1998:57-79. 

8. Statistical methods for the analysis of biomedical data. Woolson RF. 
New York: John Wiley & Sons: 1987. 

9. Cowan T, Op't Holt TB. Gegenheimer C, Izenberg S. Kulkarni P. 
Effect of inner cannula removal on the work of breathing imposed by 
tracheostomy tubes: a bench study. Respir Care 2001 ,46(5 ):460- 

10. Avery ME. Tooley WH. Keller JB. Hurd SS. Bryan MH. Cotton RB. 
et al. Is chronic lung disease in low birth weight infants preventable'.' 
A survey of eight centers. Pediatrics 1987:79( 1 ):26-30. 

1 1. De Klerk AM. De Klerk RK. Nasal continuous positive airway pres- 
sure and outcomes of preterm infants. J Paediatr Child Health 2001; 

12. Lundstrom KE. Initial treatment of preterm infants — continuous pos- 
itive airway pressure or ventilation? Eur J Pediatr 1996:155 SuppI 

13. Contencin P. Narcy P. Size of endotracheal tube and neonatal ac- 
quired subglottic stenosis. Study Group for Neonatology and Pedi- 
atric Emergencies in the Parisian Area. Arch Otolaryngol Head Neck 
Surg 1993:1 19(8):815-819. 

14. Sherman JM. Nelson H. Decreased incidence of subglottic stenosis 
using an "appropriate-sized" endotracheal tube in neonates. Pediatr 
Pulmonol 1989.6(3):18.3-185. 

15. Sherman JM. Lowitt S. Stephenson C. Ironson G. Factors influenc- 
ing acquired subglottic stenosis in infants. J Pedialr 1986;109(2): 

RESPlRATOR^• Care • September 2002 Vol 47 No 9 


Case Reports 

Huge Pulmonary Arteriovenous Fistula: Diagnosis and Treatment 
and an Unusual Complication of Embolization 

Oliver Kretschmar MD, Peter Ewert MD, Hashim Abdiil-Khaliq MD, Mustafa Yigitbasi MD, 
Heinz R Zurbriigg PhD. Roland Hetzer PhD, and Peter E Lange PhD 

We report the case of a 42-year-old woman with Rendu-Osler- Weber syndrome (hereditary hem- 
orrhagic telangiectasia) and a huge pulmonary arteriovenous fistula that involved the entire right 
middle lobe. She had a history of dyspnea and intermittent atrial flutter for 6 months. A chest 
radiograph showed a discrete shadowing of the middle part of the right lung. Arteriovenous fistula 
was suspected based on the echocardiographic finding of immediate bubble detection in the left 
atrium on introducing echocardiographic contrast medium into the venous system. Atrial shunt was 
excluded. Angiography revealed a huge pulmonary arteriovenous Fistula in the entire middle lobe 
of the right lung. A trial of interventional embolization was performed, but the size of the fistula 
made it impossible to achieve complete closure of all segmental fistulas. Furthermore, the patient 
complained of unusual, severe chest pain after implantation of the first coil, so that the coil had to 
be removed. Therefore the patient underwent surgical resection of the entire right middle lobe and 
the upper part of the right lower lobe. Anatomy was clearly delineated and all connecting vessels 
were suture-closed, but both lungs showed diffuse microscopic superficial pulmonary arteriovenous 
fistulas, which were too small to be detected by angiography and which were also partl> closed. The 
postoperative course was uneventful: the patient recovered completely, she no longer had shortness 
of breath, and blood gas analysis showed normal P^,,,- It 's not clear whether the patient's improved 
physical performance will last, because the development of diffuse microscopic arteriovenous fis- 
tulas bilaterally in the lungs is not predictable. Therefore close follow-up is necessary and in the case 
of recurrence (ie, enlargement of the existing small fistulas), early interventional embolization 
should be performed. Key words: pubmmary artehovenoiis fistida. tninscatheter coil einboli:aliou. 
surgical resection, pneitmoucctomy. Reiulu-Osler-Weher syndrome, hereditaiy hemorrhagic telangiecta- 
sia, embolization. [Respir Care 2002;47(9):998-l()()l | 


Pulmonur\ arlerimenous (AV) tisiulas are vascular, 
mainly congenital, mal formations, which are associated in 
60'7r of cases with Rcndu-OsJer- Weber syndrome (hered- 
itary hemorrhagic telangiectasia).' These lesions are 

Oliver Kretsclimar MD. Peter Ewert MD. Hasliim Abdul-Klialiq MD. 
Mustafa Yigitbasi MD. and Peter E Lange PtiD are affiliated with the 
Department of Pediatric Cardiology; Heinz R Zurbriigg PhD and Roland 
Hel/er PhD are affiliated with the Department of Cardiothoracic and 
Vascular Surgery — Deutsches Hcr//entrtim Berlin. Germany. 

Correspondence: Oliver Kretschmar MD. Deutsches Her//enlrum Berlin. 
Abteilung fiir Angeborenc Her/lchler/Kinderkardiologic. Augustenburger 
Plat/ I. D-13305 Berlin. Germany. E-mail; kretschniar(s'dh/, 

thought to represent persistent primitive AV communica- 
tions from pulmonary buds that fail to mature into capil- 
lary beds and thereby function as persistent right-to-left 
shunts.- Multiple lesions are found in 33-509^ of patients 
and can be bilateral in up to lO^.-'-* 

Congenital pulmonary AV fistulas cause intrapulmo- 
nary right-to-left-shunt. Because of the amount of shunt 
\ olume. patients clinically present with dyspnea, cyanosis, 
clubbing, or erythrocytosis.-*-^ Ventricular failure may de- 
velop. Further possible complications are thrombus for- 
mation and paradoxical embolism with systemic infarc- 
tion. Fistulas can be effectixely treated by either surgical 
resection' " ^ or transcatheler coil emboli/aiion.'' "" 

We report a patient with a huge pulmonary AV fistu- 
la — to our know ledge the biggest e\er reported — who pre- 
sented with typical clinical signs. The la\ored procedure 


Re,spiratory Care • September 2002 Vol 47 No 9 

Huge Pui monarv Artfriovfnous Fistula 


Fig. 2. Right pulmonary arteriograms, a: Frontal view, b; Lateral 
view. Multiple small arteries fed the arteriovenous malformation, 
which was drained by a single pulmonary vein (arrow). 

Fig. 1. Chest radiograph shows discrete circumscribed, tabulated 
density in the middle part of the right lung (arrow). 

Fig. 3. a: Intraoperative situs of the entire pulmonary right middle 
lobe, b: Macroscopic view of the extirpated pulmonary lobe shows 
multiple dilated fistulas and the draining pulmonary vein. 

of coil OCL-Iusion was not possible because of the size of 
the AV malformation, which had multiple feeding arteries, 
and which caused unusual severe chest pains after implan- 
tation of the first coil. The coil had to be removed. Sur- 
gical resection was successful. 

Case Report 

A 42-year-old woman with Rendu-Osler-Weber syn- 
drome was referred w ith a 6-month history of dyspnea and 
intennittent atrial flutter. She had experienced reduced ex- 
ercise tolerance, and she reported 2 unclear syncopal events. 
The physical examination showed discrete scattered telan- 
giectatic lesions as well as a grade 2/6 continuous murmur 
heard best in the region of the lower part of the right lung. 
Cutaneously measured oxygen saturation was 93% at rest. 
Orthodeoxia was not observed. 

A chest radiograph (Fig. 1) showed a discrete, circum- 
scribed, lobulated density in the middle part of the right 
lung. An echocardiogram showed borderline left atrial and 
ventricular enlargement, with good biventricular function. 
AV fistula was suspected based on the echocardiographic 
finding of immediate bubble detection in the left atrium on 
introducing echocardiographic contrast medium into the 
venous system. Patent foramen o\ale and atrial septal de- 
fect were excluded. 

Cardiac catheterization indicated normal intracardiac 
pressures and an aortic oxygen saturation of 92*^ under 
sedation. Angiograms demonstrated a large pulmonary A V 

fistula in the entire middle lobe of the right lung (Fig. 2). 
Large veins drained into the left atrium. 

Interventional embolization was attempted, but because 
of the size of the fistula it was impossible to achieve 
complete closure of all segmental fistulas. There were mul- 
tiple feeding arteries to a large pulmonary AV malforma- 
tion, which could not be occluded completely with coils or 
another device (Amplatzer Duct Occluder. AGA Medical, 
Golden Valley. Minnesota). In addition the patient com- 
plained of sharp pain over the right side of the chest, 
increasing during inspiration, as soon as the coil was im- 
planted into one of the main feeding arteries. The ce)il was 
explanted and the pain immediately stopped. 

Therefore the patient underwent surgical resection of 
the right middle lobe and the upper part of the right lower 
lobe. The anatomy was clearly delineated and all connect- 
ing vessels were suture-closed (Fig. 3). Both lungs showed 
diffuse microscopic superficial pulmonale AV fistulas, 
which were too small to be detected by angiography and 
which were also partly closed. Histology showed an AV 
malformation in the extirpated lobe. 

The postoperative course was une\cntlul and the patient 
recovered completely. Cutaneously measured oxygen sat- 
uration rose to 9^% on room air and blood gas analysis 
show ed normal P ,,) . The continuous murmur w as no longer 

The patient was discharged on the seventh day after 
surgery. A chest ratliograph showed a well-expanded lung. 
Slic no longer hail shortness o( breath, and within the 

RESP1R.ATORV Care • September 2002 Vol 47 No 9 


Huge Pulmonary Arthrioyhnolis Fistula 

fi)llow-up period of 7 months she had a lasting improve- 
ment in exereise pert'ornianee. A contrast echocardiogram 
and a control angiography 6 months after surgery revealed 
no residual pulmonary fistulas. Intracardiac and intrapul- 
monary pressures were normal. 


Abnormal AV communications in the lung are presumed 
to be present at birth, although they are not always appar- 
ent. Usually they grow with age." The clinical presenta- 
tion of our patient is typical for A V malformations. At the 
late age of 41 years she developed exertional dyspnea, 
fatigability, and atrial flultci. which are found in one third 
of patients.-" She also reported 2 unclear syncopal events. 
Cerebral symptoms such as seizure, brain abscess, tran- 
sient cerebral ischemia, and stroke are common and can be 
explained by sludging due to polycythemia, fragmentation 
of a local thrombus, or paradoxical embolism. '-"-^ Our pa- 
tient presented with cutaneous telangiectasia, which can be 
found in 3()'7r of adults because of the high association 
with Rendu-Osler-Weber syndrome.'^ Cutaneous oxygen 
saturation values depend on the degree of right-to-left shunt. 
As in our case, hypoxemia is in S()9f of cases refractory to 
supplemental oxygen. '-* Sometimes there is additional orth- 
odeoxia due to the lowering of left atrial pressure. Other 
clinical signs, such as bleeding, which are found in 109?- of 
patients, with epistaxis or hemoptysis,"* were not observed 
in our patient. 

The initial investigation should include a chest radio- 
graph and cutaneous measurement of oxygen saturation or 
a blood gas analysis first performed while the patient 
breathes room air and then again while breathing lOOVr 
oxygen.-* ''' Contrast echocardiography is a very good and 
simple diagnostic tool to confirm pulmonary right-to-left 
shunting.-* ''"''' After injection of agitated saline into a pe- 
ripheral vein, a cloud of bubbles appears in the left atrium, 
confirming a right-to-left shunting, as gas bubbles do not 
survive the normal pulmonary capillary bed. If a single 
pulmonary vein with bubbles entering the left atrium can 
be detected, anatomic localization of the lesion is possible. 
F-urlhermore. contrast echocardiography allows assessment 
of the efficacy of embt)lization therapy and is an effective 
test to exclude the presence of pulmonary AV fistulas in 
patients with Rendu-Osler-Weber syndrome.^ 

Remy et al''' proposed chest computed tomography as 
the next diagnostic step. They could clearly establish the 
diagnosis of pulmonary fistulas in 959c of patients who 
were assessed with .Vdimensional helical computed to- 
mography. Currently, spiral computed tomography offers 
the least invasive and least expensive method to establish 
the presence of pulmonary fistulas.-' ''' hut it is a time- 
consuming process and offers little atkiliional miormation 

for a physician who is experienced in treating these le- 

On conxenlional nuclear magnetic resonance images fis- 
tulas are often invisible. Berthezene et al-" presented ga- 
dolinium-enhanced pulmonary magnetic resonance angiog- 
raphy as a new noninvasive approach to detect AV 
malformations. However, the sensitivity and reproducibil- 
ity of that technique for diagnosing pulmonary AV mal- 
formations still needs to be established. 

Because untreated lesions with hemodynamic impor- 
tance are associated with 1 1% mortality and 2bV( morbid- 
ity,' patients with large pulmonary AV fistulas should be 
treated. Therapeutic options include percutaneous occlu- 
sion with metallic coils or occlusion balloons, and surgical 

Interventional treatment has become the mainsta) of 
therapy for most patients during the last decade.-' " "' The 
shortcomings of occlusion balloons are that they are ex- 
pensive and may deflate prematurely, although this is rare. 
Therefore the use of embolic coils is preferred. Coil oc- 
clusion was demonstrated to be an effective therapeutic 
modality.^'' '""' Only a few complications have been de- 
scribed, including fever, dissection of the pulmonary ar- 
tery, paradoxical embolism, and pulmonary infarc- 
tion. '■■'■''■'""^ Hirota et al" reported that 2 of 9 patients who 
presented with huge fistulas and who were treated with 
transcatheter embolization died 1 year after treatment ( I of 
hemoptysis of the contralateral lung and the otiici- of pul- 
monary fibrosis). 

In our case the patient complained of sharp chest pain as 
soon as 1 feeding artery had been coil-embolized. so that 
the device had to be explanted. The reason for that acute 
intolerable chest pain is not clear. It may have been asso- 
ciated with an acute pulmonary infarction. An alternatixe 
might have been to leave the device in place and wait for 
a while, giving adequate drug therapy for the pain. Berman 
et al'" also described chest pain after inters enlional closure 
of a pulmonary AV malformation, but the pain de\eloped 
slowly, was tolerable, and vanished after 2 days. 

It is in some cases still challenging to achieve satisfac- 
tory catheter placement for delivery of the embolic de- 
vices, especially when confronted with large, complex le- 
sions. Toeliminate or reduce the incidence of recanali/ation 
( I ()''() it is important to embolize all feeding arteries. Some- 
limes it is even necessary to pack a bigger pulmonarv 
artery with coils. To embolize the fistula itself is always 
associated with the threat of embolic material escaping 
through the fistula. 

Surgical treatment ot pulmonary AV fistulas is of course 
more in\asi\e than embolization, but it is associated with 
low moihitliiN and mortality and a recurrence rale of 
< 29f.'^ Isolated ligation of great feeding arteries is of no 
benefit because of the recurrence of new communications 
between arteries and veins." Therefore a pulmonary AV 


Ri;,sp!R,vr()R^' Carb • September 2002 Vol 47 No 9 

Huge PuLMON.\K^ Aru riom.nous Fistik.a 

nialtoiiiialion should he cdniplciolN ivnunoii.'"' " It'embo- 
li/ation ihciapv has tailed, conscrv ali\c surgical excision 
(wedge i)r segiiieriiectonis ) is the prceediiie ol choice, as 
most lesions are subpleural. In oui case the patient under- 
went surgical resection of the right middle li>be and a 
wedge resection ol the upper part ol the right lower lobe 
withi>Lit an\ problems. The aiiatoni\ was clearly delineated 
and all connecting vessels were suture-closed. A control 
angiographs d months alter surgery revealed no residual 
pulmonary I'isiula. 

it is tun clear whether our patient's impnned physical 
pert'orniance v\ill last, because the de\elopmenl otditTuse 
microscopic AV fistulas bilaterally in (he lungs is not pre- 
dictable. Therefore close follow -up is necessary, and in the 
case of recurrence through enlargement of the existing 
small fistulae. early interventional embolization should he 


1. Dines DE. Seward JB. Bematz PE. Pulmonary arteriovenous fistulas. 
Mayo Clin Proc l98.^;.'i8(3):l76-ISI. 

2. Anabtawi IN. Ellison RG. Ellison LT. Pulmonary arteriovenous an- 
eurysms and fistulas: anatomical variations, embryology and classi- 
fication, .■^nn Thorac Surg I W."!; 1:277. 

.V Friedlich .A. Bing RJ. Blount SO, Physiological studies in congenital 
heart disease: circulatory dynamics in the anomalies of venous return 
in the heart: including pulmonary AV fistula. Bull Hopkins Hosp 

4. Pick A. Deschamps C. Stanson AW. Pulmonary arteriovenous fis- 
tula: presentation, diagnosis, and treatment. World J Surg 1999: 

.5. Yavuz AS. Nisanei Y. Umman S. Sargin D. Dincol G. |Arterio- 
venous fistula of the lung: a rare cause of erylhrocytosis.j Wien Klin 
Wochenschr I99S:I I0|2I ):77()-772. ariicli' in Gciiiwn 

6. Fiane AE. Stake G. Lindberg HL. Congenital pulmonary arterio- 
venous fistula. Eur J Cardiothorac Sura I995:9(.^|:166-16S. 




7. Marchesani F. Cecarini I,. IVla R. Catalini G. Sabbatini A. Fianchini 
A. Sanguinetii CM. Pulmonary arteriovenous fistula in a patient with 
Rendu-Osler-Weber syndrome. Respiration l997:r>l(.Si:.Vi7-.37(). 

8. Mover JH. Giant/ G. Brest AN. Pulmonary arteriovencms 
Am J Med 1962:32:4 1 7-43.S. 

9. Beck FJ. Neuerburg .1. Sigmund M. Schmil/ i.. Guntlier RW. llanralh 
P. I.^n increase in cardiopulmonary exercise tolerance alter the em- 
bolization of a pulmonary arteriovenous fistula. | Dtsch Med Wochen- 
schr 1993:1 18(33): 1 193-1 198. iirtUU' in Gcmwii 
Berman W Jr. Fripp RR, Raisher BD. Yabek SM. Transcalheter 
occlusion of large pulmonary arteriovenous fistula, Cathet Cardio- 
vase Intervent 2()00:.';i(2):22()-222. 

Castaneda-Zuniga W, Epstein M. ZollikoferC, Nalh PH, I'ormanek 
.■\. Ben-Shachar G. Aniplat/ K. Hmholi/ation of multiple pulmonary 
artery fistulas. Radiology I9S():I34(2|:.M)9-.3I0, 
Hatfield DR. Fried AM. Therapeutic emboli/ation ol dilluse pulmo- 
nary arteriovenous malforiiiations, .•\.IR ,\m .1 Koenlgeiinl I'lXl; 
1 37(41:861-863. 

Hirota S, Matsumoto S. Toniita M. Sako M. Kono M. Pulmonary 
arteriovenous fistula: long-term results of percutaneous transcalheter 
einbolization with spring coils. Radiat Med 1998:16(1 ); 1 7-23. 

14. Keller FS. Rosch J. Barker AF. Nath PH. Pulmonary arteriovenous 
fistulas occluded by percutaneous introduction of coil springs. Ra- 
diology I984:I52(21:37.V37.'S. 

Kirsch LR. Sos TA. Engle MA. Successful coil emholi/ation for 
diffuse, multiple pulmonary arteriovenous fistulas. .'Xm Heart .1 1991: 
122(1 Pt 11:245-248. 

Liau CS. Wang JK. Wu MH. Chii IT. Tran.scatheter closure of a huge 
pulmonary arteriovenous fistula with emboli/'ation coils. Cathet Car- 
diovasc Diagn 1997:42(31:286-289. 

17. Halliday AW. Mansfield AG. Congenital arterio\ciious malforma- 
tions. Br J Surg I993:80( 1 ):2-3. 

18. Ference BA. Shannon TM, While RI. /awin M. Burdge CM. Life- 
threatening pulmonary hemorrhage with pulmonary arteriovenous 
malformations and hereditary hemorrhagic telangiectasia. Chest 1994: 

Remy J. Remy-Jardin M. Wattinne L. Deffontaines C. Pulinonary 
arteriovenous malformations: evaluation with CT of the chest before 
and after treatment. Thorac Radiol I992:I82(3):8()9-816. 

(). Berthezene Y. Howarth NR. Revel D. Pulmonary arteriovenous fis- 
tula: detection with magnetic resonance angiography. Eur Radiol 




Respiratory Care • September 2002 Vol 47 No 9 


Anticipatory Use of Venoarterial Extracorporeal Membrane 
Oxygenation for a High-Risk Interventional Cardiac Procedure 

Tina B Carmichael RRT. Edward P Walsh MD. and Stephen J Roth MD MPH 

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a valuable technique 
in the critical care of children with congenital heart disease who require mechanical cardiorespi- 
ratory support. The use of VA ECMO in cardiac patients has expanded from an extension of 
intraoperative cardiopulmonary bypass and now includes rescue therapy during cardiopulmonary 
resuscitation, temporary circulatory support for reversible heart failure, and bridge support pre- 
ceding heart or heart/lung transplantation. In the majority of clinical applications VA ECMO is 
used in reaction to impending or ongoing cardiorespiratory failure and not in anticipation of an 
induced change in clinical status. We describe the anticipatory use of VA ECMO to prepare a 
patient with complex cyanotic congenital heart disease for a high-risk interventional cardiac cath- 
eterization. A 2.5 kg neonate with severe Ebstein's anomaly of the tricuspid valve and recurrent 
episodes of life-threatening supraventricular tachycardia was electively cannulated for VA ECMO 
in the cardiac intensive care unit. She underwent successful electrophysiologic mapping and trans- 
catheter radiofrequency ablation of an accessory conduction pathway, resulting in termination of 
the tachycardia. Following an uncomplicated ECMO course she was decannulated in the cardiac 
intensive care unit and subsequently discharged home in stable condition. The case illustrates the 
proactive use of ECMO during a procedure in which severe hemodynamic instability could be 
predicted. We discuss this concept of ECMO use in the context of accepted indications for ECMO 
in cardiac patients and encourage an expanded role for its use to prevent cardiorespiratory collapse 
in planned interventions on compromised patients who are at risk of acute deterioration. Key 
words: venoarterial extracorporeal membrane oxygenation, ECMO. Ebstein 's anomaly, supraventricular 
tachycardia, interventional cardiac catheterization. [Respir Care 2002:47(9): 1002-1006] 


The use of venoarterial extracorporeal membrane oxy- 
genation (VA ECMO) expanded substantially during the 
1990s in centers managing large numbers of pediatric pa- 
tients with complex congenital and acquired heart defects.' 
The usual indication for mechanical circulatory support 
with VA ECMO in pediatric cardiac patients is inadequate 

Tina B Carmichael RRT is alTilialed with the Departments of Respiratory 
Care and Anesthesia; tdw ard P Walsh MD and Stephen J Roth MD MPH 
are alTilialed with the Depaitnieni ot Cardiology — Children's Hospital 
Boston. Massachusetts. 

Tina B Carmichael RRT presented a version ot this report at the Ophn 
Forum of the 4.'iih International Respiratory Congress, Las Vegas. Ne- 
vada. December 13-16. UW). 

Correspondence; Stephen J Rolh Ml:) MPH. Department of Cardiology. 
Children's Hospital Boston, .3(K) Longwood Avenue, Boston MA 021 15. 

oxygen delivery. Typical causes include low cardiac out- 
put (following cardiac surgery, from acute myocarditis, or 
from end-stage cardiomyopathy), severe cyanosis (due to 
intracardiac right-to-left shunting leading to myocardial 
failure), and severe hypoxemia from acute respiratory fail- 
ure. VA ECMO has also been used as a rescue strategy for 
selected cardiac patients who suffer in-hospital cardiac 
arrest and do not respond to conventional resuscitation 
measures in the intensive care unit (ICU).- As ICU teams 
have gained more experience with VA ECMO in cardiac 
patients who suffer life-threatening decompensations of 
cardiorespiratory function, increased interest has devel- 
oped in identifying patients at risk of profound cardiac or 
respiratory failure so that these events can be averted by 
the proactive use of mechanical support. 

This case presents the anticipatory use of VA ECMO in 
a neonate with severe cyanosis and airhythmia caused by 
Ebstein"s anomaly. Ebstein's anomaly is a rare (1/100,000 
live births) congenital heart defect with a broad spectrum 
of clinical presentations, ranging from se\'ere cyanosis and 


Respiratory Care • September 2002 Voi 47 No 9 

Anticipator'^ Hsi-. oi- Vi'NOAKri kiai F.xiraioki'okhai, Mi-mhkanh Oxygenation 

Normal Heart 

Ebstein's Anomaly 



Fig. 1. Anatomy of the normal heart and Ebstein's anomaly. Ao 
right atrium. RV = right ventricle. 


Downwardly displaced 
tricuspid valve leaflets 

aorta. LA =-- left atrium. LV = left ventricle. PA = pulmonary artery. RA 

congestive heart failure in neonates to mild oxygen de- 
saturation only upon vigorous exercise in adults.' ' Ana- 
tomically. Ebstein's anomaly is characterized by down- 
ward displacement of the posterior and septal leaflets of 
the tricuspid valve, together with valve leaflet deformities 
(Fig. 1 ). The portion of the right ventricle above or on the 
atrial side of the displaced valve leaflets becomes abnor- 
mally thinned, a process known as atrialization of the right 
ventricle. When the right atrium contracts, blood is ejected 
into both the atrialized and distal portions of the right 
ventricle. During right ventricular contraction, blood in 
both portions of the right ventricle can be ejected back- 
ward (regurgitation) into the right atrium as well as for- 
ward into the main pulmonary artery. Substantial regurgi- 
tation can elevate the right atrial pressure, leading to a net 
shunting of systemic venous blood across a coexisting 
atrial septal defect or patent foramen ovale into the left 
atrium (right-to-left shunt), causing cyanosis. The right 
atrium is almost always enlarged, especially in patients 
with substantial tricuspid regurgitation: this produces an 
increased heart size on chest radiograph. When a large 
portion of the right ventricle is atrialized. ventricular func- 
tion is usually diminished and forward flow into the main 
pulmonary artery is additionally compromised. These prob- 
lems generating pulmonary blood flow are exacerbated in 
newborns who have relatively increased pulmonary vas- 
cular resistance in the first hours and days after birth. 

Abnormalities of the heart's electrical conduction sys- 
tem are common in patients with Ebstein's anomaly. The 
electrocardiogram often shows delayed conduction in the 

right ventricle (right bundle branch block). There is also a 
higher incidence of accessory atrioventricular conduction 
pathways, which predispose Ebstein's anomaly patients to 
sudden episodes of supraventricular tachycardia (SVT) that 
can lower cardiac output and increase cyanosis. The Wolff- 
Parkinson-White syndrome is relatively cominon in Eb- 
stein's anomaly, but occasional patients have a rarer form 
of accessory pathway known as a Mahaim fiber."-' SVT 
caused by either type of accessory pathway is typically 
managed first with antiaiThythmia medications. If pharma- 
cologic therapy does not produce adequate arrhythmia con- 
trol or is poorly tolerated, patients are refeired for cardiac 
catheterization. During catheterization the accessory con- 
duction pathway is mapped by intracardiac electrophysi- 
ologic techniques, and. if technically feasible, the pathway 
is destroyed (ablated) by the targeted application of radio- 
frequency electrical current via a transcatheter approach. •"' 
The diagnosis of Ebstein's anomaly is made by echo- 
cardiography, and cardiac cathcleri/ation is seldom re- 
quired to define the structural abnormalities. In severe 
cases the diagnosis can be made in the fetus when a ixiu- 
tine 4-chamber view of the heart is obtained as part of a 
screening obstetrical ultrasound. 

Case Summary 

Severe Ebstein's anomaly was diagnosed by fetal ultra- 
sound in a twin fetus at 28-29 weeks gestational age, and 
the mother was referred for deli\ery to a hospital with a 

Respiratory Care • Septe.mber 2002 Vol 47 No 9 


Anhcii'mory Use of Venoarterial Extracorporeal Membrane Oxygenation 

Fig. 2. Chest radiograph at admission. The heart Is markedly di- 
lated and globular in appearance, and the lungs have decreased 
vascular markings consistent with reduced pulmonary blood flow. 
The trachea is intubated and a gastric tube has been inserted into 
the stomach. 

high-risk obstetrical service and level III neonatal ICU 
near our hospital. The pregnancy was otherwise unremark- 
able. Labor was induced at 37 weeks gestational age, and 
the patient was born by vaginal delivery as twin B. Her 
birthweight was 2.5 kg and her Apgar scores were 6 and 8 
at 1 and 5 minutes, respectively. She was cyanotic, with 
oxygen saturation (measured via pulse oximetry (SpoJ) of 
70-80% while receiving supplemental oxygen. The tra- 
chea was intubated for mechanical ventilation, and pros- 
taglandin E| was administered via continuous intravenous 
infusion to maintain a patent ductus arteriosus before trans- 
fer to our cardiac ICU. 

A chest radiograph on admission demonstrated massive 
cardiac enlargement, clear and well-expanded lungs, and 
decreased pulmonary blood flow (Fig. 2). An echocardio- 
gram confirmed the diagnosis of severe Ebstein's anom- 
aly, showing marked right atrial dilation and severe tri- 
cuspid regurgitation. The patient was treated with inhaled 
nitric oxide at 80 parts per million and intravenous milri- 
none, along with oxygen to vasodilate the pulmonary vas- 
culature, lower pulmonary vascular resistance, improve 
pulmonary blood flow, and thereby raise ?.,„, above 40 
mm Hg. These therapies succeeded in increasing P^q^ to 
50-60 mm Hg. 

In the first 24 hours after birth she developed episodes 
of tachycardia with a wide QR.S ct)mplex, to he;u-t rates of 
240-260 beats per minute. Upon electrophysiologic eval- 
uation the tachycardia appeared to be caused by a Mahaim 
fiber running between the right atrium and richt ventricle. 

The tachycardia caused severe hypotension, which on iniil- 
tiple occasions required cardiopulmonary resuscitation with 
chest compressions and electrical cardioversion (Fig. 3). 
Sequential treatment over 7 days with the intravenous an- 
tiarrhythmia medications digoxin, procainamide, and fi- 
nally aniiodaronc failed to prevent recurrences of SVT. 
Serial echocardiograms during this period showed pro- 
gressive deterioration of both left and right ventricular 
function, and dopamine was started for additional inotro- 
pic support. Because episodes of life-threatening SVT con- 
tinued to occur despite maximal antiarrhythmic therapy, 
the only intervention deemed possible to terminate the 
SVT was anatomic elimination of the Mahaim fiber. Ra- 
diofrequency ablation of the accessory conduclioii path- 
way during cardiac catheterization was determined to be 
the preferred alternative to a surgical pathway disruption 
during open-heart surgery with cardiopulmonary bypass. 

However, an ablation procedure during cardiac cathe- 
terization posed substantial risks. Intracardiac mapping to 
determine the precise location of the Mahaim fiber would 
require the patient to be in SVT for many minutes, and 
sustained SVT caused severe hypotension. The catheter- 
ization was likely to be prolonged, given the technical 
challenges of accessory pathway ablation in a 2.5 kg ne- 
onate. It was highly likely that the patient would require 
mechanical circulatory support to maintain adequate car- 
diac output during the procedure, and the team wished to 
avoid the risks of initiating mechanical support in the midst 
of a cardiopulmonary resuscitation, so we elected to ini- 
tiate VA HCMO prior to the catheterization to avoid the 
anticipated hemodynamic instability. Following the induc- 
tion of anesthesia and neuromuscular blockade, the patient 
was cannulated with a 10 French \enous cannula (Bio- 
Medicus, Medtronic. Minneapolis. Minnesota) in the right 
internal jugular vein and an 8 French arterial cannula iBii'- 
Medicus. Medtronic. Minneapolis. Minnesota) in the right 
carotid artery via cutdown in the cardiac ICU before trans- 
fer to the catheterization laboratory. An ECMO flow of 
1 10 niL/kg/min and sweep gases of 0.75 L carbogen and 
0.25 L oxygen maintained adequate systemic blood pres- 
sure (mean arterial pressure 40-45 mm Hg) and gas ex- 
change during the procedure. Accessory pathway mapping 
and ablation were difficult but successful, and the patient 
was in SVT for approximately I hour during the 4-hoiM' 
procedure. There was a brief period of decreased venous 
return, which was corrected by minor repositioning of the 
venous caniuila. 

The patient was transported back U) the caidiac ICU and 
maintained on ECMO support for 72 hours after comple- 
tion of the catheterization, to allow lime for improvement 
of ventricular function. No ECMO-related complications 
occurred. Cranial ultrasounds performed just prior to can- 
nulalion and on day 2 of ECMO support showed no ab- 
normalities. A repeat study the day after dccannulation 


Respiratory Care • September 2002 Vol 47 No 9 

ANricii'ATORY L'si: oi- Vi-noakh.kial E\trac()ri>()Ki:al Membrane Oxygenaiion 

Normal Rhythm APB Tachycardia ^ 

ECG 1 


25.0 mm/s Strip 1 

Fig. 3. Electrocardiogram (ECG) (upper tracing) and arterial blood pressure (ABP) waveform (lower tracing) recorded on the bedside monitor 
at the beginning of an episode of supraventricular tachycardia (SVT). The left portion of the ECG shows a normal atrial rhythm, at 160 beats 
per minute, that converts to SVT, at approximately 250 beats per minute, in the right portion, following a single atrial premature beat (APB). 
Note the change in the arterial pressure waveform from a pulsatile to a flattened morphology with the initiation of SVT. The patient became 
hypotensive and required cardiopulmonary resuscitation when the SVT persisted. 

showed a small, left-sided subdural fluid collection. Both 
neck vessels were reconstructed at the time of decannula- 
tion in the cardiac ICU. She was extubated from mechan- 
ical ventilation 9 days after the ablation and discharged 
home 27 days later, with an Sp^^ of 80-90% on room air, 
A cranial computed tomography scan performed at age 5 
months to reevaluate her central nervous system (CNS) 
was normal. No episodes of SVT have occurred since the 
ablation, and she subsequently underwent a successful re- 
parative cardiac surgical procedure at 21 months, which 
included a tricuspid valvuloplasty, patch fenestration of 
the atrial .septum, and right atrial plication. At recent fol- 
low-up, at 3 1 months, she had an Spo, of 98% and normal 
somatic growth. No evidence of developmental delay has 
been noted at well-child visits upon screening with the 
Denver Development Assessment (Denver 11 ), and her par- 
ents report no differences in her skills or activities in com- 
parison with her healthy twin. 


As experience with mechanical support of the circula- 
tion in pediatric cardiac patients increases, our understand- 
ing of the probabilitN of success or failure of VA ECMO 
for a variety of applications is improving. Initially VA 
ECMO was regarded as a technique for extending the use 
of cardiopulmonary bypass from the operating room to the 
ICU in patients who were unable to make the transition 
from mechanically-assisted to unassisted circulation with 
medical therapy alone.'' '" The indications for ECMO sup- 
port in cardiac patients have expanded substantially since 
then. and. currently, typical indications in these patients 
also include:' 

1. Progressive postoperative myocardial failure 

2. Progressive myocardial failure in medical disorders 
(eg, acute viral myocarditis, chronic dilated cardiomyop- 
athy), including bridge support to cardiac transplantation 

3. Reversible pulmonary hypertension (eg. following 
repair of obstructed total anomalous pulmonary venous 
return or mitral stenosis) 

4. Arrhythmia unresponsive to medical therapy (eg. sus- 
tained ventricular or supraventricular tachycardia) 

5. Severe cyanosis from intracardiac or intrapulmonary 
(eg. pulmonary arteriovenous malformations) right-to-left 

6. Acute respiratory failure (eg, pneumonia, meconium 
aspiration, or sepsis in the newborn) 

7. Rescue therapy during cardiopulmonary resuscita- 

In the case presented here. VA ECMO was used to 
preserve adequate cardiac output and systemic blood pres- 
sure at catheterization during a planned intracardiac elec- 
trophysiologic study and accessory pathway ablation. The 
literature includes isolated case reports and occasional pa- 
tients in small series that demonstrate the planned use of 
VA ECMO for catheter-based interventions. VA ECMO 
has been used to support cardiac output during balloon 
aortic valvuloplasty in critical valvar aortic stenosis," dur- 
ing stent implantation in severe, unilateral branch pulmo- 
nary artery stenosis.'- and during balloon or blade atrial 
septostomy in newborns with hypoplastic left heart syn- 
drome who have severe left atrial hypertension from re- 
strictive or intact atrial septum." To our knowledge, this 
case represents the first example of planned VA ECMO to 
support cardiac output during an interventional electro- 
physiologic study. 

Respiratory Care • September 2002 Vol 47 No 9 


Anticipatory Use ok Vbnoarterial Extracoki'okhal Membrane Oxygenation 

The anticipatory use of VA ECMO tor inters eiitioiial 
cardiac catheterizations could also be considered in other 
high-risk scenarios. Patients with severe, bilateral pulmo- 
nary artery stenoses, which frequently occur in those with 
tetralogy of Fallot and pulmonary atresia, can develop 
profound cyanosis and right ventricular failure and can 
suffer cardiac arrest during catheter-based balloon dilation 
of stenotic pulmonary artery segments. '■* Patients with ven- 
tricular septal defects and poor \entricular function from 
large left-to-right shunts are also at risk of substantial he- 
modynamic instability during the manipulations required 
to position and deploy occluder de\ ices into the deficient 
ventricular septum.''^ 

For many of the aforementioned indications, initiating 
ECMO support has become a focus of management, to 
prevent serious end-organ damage or cardiac arrest. Though 
impressive improvements in survival to hospital discharge 
have been achieved with ECMO as a cardiopulmonary 
resuscitation technique, the risks of initiating ECMO dur- 
ing a cardiac arrest remain high, especially to the CNS, 
and should be avoided whenever possible."' The neonate 
described in this case report serves as an example of a 
strategy to initiate ECMO support during a period of rel- 
ative hemodynamic stability to reduce risk. This patient is 
likely, at least in part, to be achieving normal develop- 
mental milestones because she was not subjected to a pro- 
longed period of low cardiac output and reduced cerebral 
perfusion during cardiac catheterization. 

ECMO support should only be initiated with a clear 
understanding of the potential complications. A recent re- 
view of mechanical circulatory support in cardiac patients 
at Children's Hospital Boston' reported the following non- 
cardiac complications: 

1 . Hemorrhage, most commonly at cannulation sites, the 
CNS, and the gastrointestinal tract, related to the require- 
ment for continuous anticoagulation 

2. Neurologic, including seizures and cerebral infarction 
in addition to CNS hemorrhage 

3. Nosocomial infection 

4. Mechanical malfunction such as cannula dislodgment 
and tubing rupture 

."i. Renal failure. 

The benefits of ECMO support must be balanced against 
these potential complications in the analysis of every pa- 
tient's candidacy for ECMO. 

We can expect that the indications for use of V A ECMO 
uill increase as centers specializing in the care of patients 
with complex congenital heart ilisease gain experience w ith 
different patient pi)pulalions. Close follow-up of neuro- 
logic development and cardiorespiratory function of sur- 
vivors will be essential to optimize the application of this 
labor-intensive and costly technology. 


The authors ihank the patient's cardiologist. Gerald R Marx MD. De- 
partment of Cardiology, Children's Hospital Boston, for his guidance 
with clinical management and review of the manuscript. We also wish to 
thank Peter C Laussen MBBS. Departments of Anesthesia and Cardiol- 
ogy, Children's Hospital Boston, for his comments on the manuscript. 


1. Wessel DL, Almodovar MC. Laussen PC. Intensive care manage- 
ment of cardiac patients on extracorporeal membrane oxygenation. 
In. Duncan BW. editor. Mechanical support for cardiac and respi- 
ratory failure in pediatric patients. New York: Marcel Dekker; 2000; 

2. Duncan BW. Ibrahim AE. Hraska V. del Nido PJ. Laussen PC. 
Wessel DL. et al. Use of rapid-deployment extracorporeal membrane 
oxygenation for the resuscitation of pediatric patients with he;irt 
after cardiac arrest. J Thorac Surg |y98;I I6(2):.W5-3I 1. 

-^. Celermajer DS. Bull C, Till JA. Cullen S, Vassillikos VP, Sullivan 
ID. et al. Ebstein's anomaly: presentation and outcome from fetus to 
adult. J Am Coll Cardiol I994:23( I ):170-I76. 

4. Celermajer DS. Cullen S. Sullivan ID. Spiegelhalter DJ. Wyse RKH. 
Deanfield JE. Outcomes in neonates with Ebstein's anomaly. J Am 
Coll Cardiol I992;I9(5):I041-1046. 

5. Yetman AT. Freedom RM. McCrindle BW. Outcome in cyanotic ne- 
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6. Giuliani ER. Fuster V, Brandenburg RO. Mair DD. Ebstein's anom- 
aly: the clinical features and natural history of Ebstein's anomaly of 
the tricuspid valve. Mayo Clin Proc l979;54(.3):lfi.V173. 

7. Follath F. Hallidie-Smith KA. Unusual electrocardiographic changes 
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S. Walsh EP. Ablation therapy. In: Deal B. Wolff G, Gelband H. edi- 
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10. Soeter JR. Mamiya RT. Sprague .'XY. McNamara JJ. Prolonged ex- 
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Respiratory Care • September 2002 Vol 47 No 9 

Special Articles 

Mechanical Ventilation Stratesies: 
What's New and What's Worth Keeping? 

Dean R Hess PhD RRT FAARC 


Is Endotracheal Intubation Needed for Mechanical Ventilation? 

Is the Ventilator Circuit a Source of Ventilator-Associated Pneumonia? 

Is the Goal of Mechanical Ventilation to Normalize Blood Gases? 

Is the Goal of PEEP to Raise the P^q^ so that the Fraction of Inspired 
Oxygen Can Be Decreased? 

Are Nebulizers Superior to Inhalers During Mechanical Ventilation? 

Is Pressure Support a Simple Mode? 

Does the Endotracheal Tube Impose a Significant Resistance to Spontane- 
ous Breathing? 

Is Synchronized Intermittent Mandatory Ventilation a Useful Weaning Mode? 

Are Weaning Protocols Safe and Effective? 

Do New Ventilator Modes Facilitate Weaning? 


Many technologic and management strategies related to mechanical ventilation have been intro- 
duced in recent years. Strategies that avoid intubation and get patients extubated sooner decrease 
costs related to mechanical ventilation. In general, "people" solutions such as weaning protocols are 
preferable to "technology" solutions such as new ventilator modes. It must be remembered that 
mechanical ventilation is supportive — it is not curative — and has the potential to do harm if applied 
incorrectly. There is an increasing list of examples in which short-term physiologic outcomes such 
as improvements in blood gas values are not related to patient-important outcomes such as survival. 
When new mechanical ventilation technology and strategies are introduced, a question we need to 
ask ourselves is whether these are solutions for problems or whether these are simply solutions in 
search of problems. AVv words: nwciuiiiical vcntihition. intubation, cxtuhution. ventilator modes, wean- 
ing, protocols. [Respir Care 2002:47(9):I0()7-1()I7| 


I was very honored to present the Simon Rodbard Me- 
morial Lecture at the 2001 Annual International Scientific 

Assembly of the American Collesie of Chest Ph\sicians. I 
am equally pleased to ha\c the opportunit\ to share these 
thoughts with the readers of Respiratory Care. In recent 
years, manv new lechnolosiic and niana<jcnient stratetiies 

Dean R Hess PhD RRT FAARC is affiliated with the Depanment of 
Respiratory Care. Massachusetts General Hospital, and Harvard Medical 
School. Boston. Massachusetts. 

This article derives from the Simon Rodbard Memorial Lecture presented 
by Dr Hess at the American College of Chest Physicians' 67th Annual 

International Scienlitlc Assembly. November?. 2001. Philadelphia. Penn- 

Correspondence: Dean R Hess PhD RKI l-AARC. Respiratory Care. 
lillison 401. Massachusetts General Hospital. .'^.'> Pruil Sirecl. Boston MA 
021 14-2696. E-mail: dhessts 

Respiratory Care • September 2002 Vol 47 No 9 


Mechanical Ventilation Strategies: What's New and What's Worth Keeping? 

Craven (24 vs 48 hr) 

Dreyfuss (48 hr vs no changes) 8/28 

Kollef (1 wk vs no changes) 

Long (3/wk vs 1/wk) (MICU) 


Less Frequent 

More Frequent 














(95% CI Fixed) 




(95% CI Fixed) 

0.48 [0.29, 0.82] 
0.91 [0.42,1.95] 
1.02 [0.41, 2.53] 
0.82(0.45, 1.50] 

0.76 [0.59, 0.97] 


0.1 0.2 

Favors less 
frequent change 

5 10 
Favors more 
frequent change 

Fig. 1. A meta-analysis combining the results of randomized studies that compared the rate of ventilator-associated pneumonia (VAP) with 
extended ventilator circuit change intervals. RR = risk ratio, n - number of cases of VAP. N = total number of patients. CI = confidence 
interval. MICU -^ medical intensive care unit. NICU = neurologic intensive care unit. 

related to mechanical ventilation have been introduced. 1 
take 10 topics, briefly describe each, address some of the 
evidence, and inject some of my own bias in relation to 
each of these issues. 

Is Endotracheal Intubation Needed 
for Mechanical Ventilation? 

Since \W?< there have been more than 20 randi)mized 
controlled trials of noninvasive positive-pressure ventila- 
tion (NPPV) for acute respiratory failure, most of which 
have reported benefit from NPPV.'—* A meta-analysis of 
some of these studies reported that NPPV was associated 
with a decreased need for endotracheal intubation, partic- 
ularly in patients with acute exacerbation of chronic ob- 
structi\e pulmonary disease (COPD).^ Perhaps more im- 
portant, NPPV was associated with decreased mortality, 
again particularly for patients w ith acute exacerbation of 
COPD. A more recent mela-analysis included additional 
studies but ani\ed at the same conclusion.'' That is, NPPV 
is associated \\ ith a decreased need for endotracheal intu- 
bation and with improved sur\i\al. particularly in patients 
with acute exacerbation of COPD. 

A commonly cited study of NPPV for patients with 
acute exacerbation of COPD is that by Brochard et al.^ 
They reported that NPPV was beneficial in a number of 
areas, including a decreased need for endotracheal intuba- 
tion, fewer days in the hospital, and a sur\i\al benefit. 
However, there are a few important things about this study 
that are often overlooked. First, there were 275 patients 
who were screened to enroll S.'S patients into the study. 
This underscores the need to select patients carefully for 
NPPV. NPPV is not for all patients w iih acute respiratory 
failure, and it is not for all patients wilh acute exacerbation 
of COPD. The Brochard el al study also showed that, 
although NPPV significantly reduced the need for endo- 
tracheal intuhalion. it did not eliminate it. e\en in carefulK 

selected patients. Even w ith appropriately selected patients 
there may be as many as I in 4 who fail NPPV and need 
to be intubated. 

For patients with acute liypo.xfinic respiratory failure, is 
there a role for mask continuous positi\e airway pressure 
(CPAP)? There was a thought-provoking study recently 
published that addressed this question. Patients were ran- 
domized to either receive oxygen alone or to recei\e ox- 
ygen with mask CPAP.** One hour after the initiation of 
therapy, dyspnea was less and P.,,, was better in the pa- 
tients receiving mask CPAP. However, and perhaps more 
important, there was no difference in intubation rate or 
hospital mortality. In fact, there was a higher number of 
adverse events in patients receiving mask CPAP. .As a 
result of that study, my enthusiasm for mask CPAP for 
patients with acute hypoxemic respiratory failure has de- 
creased substantially. It is also important to point out that 
few of the patients in that stud\ had acute cardiogenic 
pulmonary edema. There is substantial e\ idence thai mask 
CPAP is beneficial in patients with acute cardiogenic pul- 
monary edema. ** 

Is the Ventilator Circuit a .Source 
of V'entilator-.\ssociated Pneumonia? 

1 submit that there is substantial e\ idence to suggest that 
ventilator-associated pneumonia (VAP) is more likely the 
result of what is aspirated around ihe cuff of the eniloira- 
cheal lube than vvhal is inhaled from the \entilalor circuit. 
What is the evidence lo suppiirl this? First, there ha\e been 
a number t)f randomized controlled trials looking at \eii- 
tilator change frequency, which showed that when venti- 
lator circuits are changed less frequentl\ there is a lower 
risk of VAP (Fig. 1 I.'" '■* In other wdrds. changing the 
tubing less frequentl\ decreases the risk of V.AP. This is 
supporteti not onl\ by randomized controlled trials but 
also a number of obser\ ational studies that suggest that the 


Respiratory Care • September 2002 Vol 47 No 9 

Mechanical Ventilahon Strategiis: Wiiai's Nlw and Wiiai's Wok hi Ki 





I 30 


■ 6mL/Kg ni2mL/Kg 





Ventilator-Free Days 

Fig. 2. In the ARDS (acute respiratory distress syndrome) Network trial, use of a volume and pressure limitation strategy (tidal volume 6 
mLVkg and plateau pressure ^ 30 cm H2O) resulted in lower mortality and a greater likelihood of being ventilator-free at 28 days. (Adapted 
from Reference 32.) 

ventilator circuit is not the principal culprit in VAP. '■''--" 
Second, there are data to show that suctioning secretions 
from above the cuff of the endotracheal tube, st) that those 
secretions are not aspirated around the cuff of the endo- 
tracheal tube, decreases the VAP rate, suggesting again 
that VAP is the result of what is aspirated around the cuff 
lather than what is breathed from the ventilator circuit.-'--'' 
Third, there have been studies showing that if the endo- 
tracheal tube is avoided w ith NPPV. there is a significantly 
lower nosocomial pneumonia rate and fewer other noso- 
comial infections such as urinary tract infections and cath- 
eter-related infections.-'' -^ I would suggest that rather than 
refer to these infections as VAP. perhaps we should refer 
to them as ciulninuhcal-tiiht'-as'^ociMed pneumonia.-'' 

Is the Goal of .Mechanical Ventilation 
to Normalize Blood 

There is now accumulating e\ idence. both expenmcnial 
and clinical, that how we set the mechanical ventilator can 
affect both biochemical and biophysical injury within the 
lungs. In other words, how we set the ventilator can result 
in tearing of the lungs and in inflammation within the 
lungs. That intlammation can move from the lung into the 
circulation and then affect distal organs downstream from 
the lung, which can result in multiple organ d\sfunctioii 
syndrome and death.'" " 

How we set the ventilator can impact paticnl siirM\al. 
This is best illustrated by the ARDS (acute respiratory 
distress syndrome) Network data.'- which showed signif- 
icantly lower mortality and significantlv more ventilator- 
free days with a tidal volume (V, ) of 6 niL/kg predicted 
body weight than with 12 mL/kg (Fig. 2). By simply re- 

ducing the Vj setting on the ventilator we can significantly 
improve patient survival. These data suggest that for every 
12 patients with acute lung injury whom we ventilate us- 
ing this low-Vj strategy, we can save the life of one pa- 
tient. This, I believe, is very compelling evidence to adopt 
this approach to the ventilation of patients with acute lung 
injury and ARDS. 

If we look closer at the ARDS Network data, we see that 
Pen, 's increased with the low-Vj strategy. However, as a 
group these patients did not have a P,,cn that was much 
greater than normal (mean 43 i 12 mm Hg). The reason 
is that these patients were ventilated with a rapid respira- 
tory rate (mean 30 ± 7 breaths/min). Even more interest- 
ing is the fact that the patients who were ventilated with 
the lower Vj had better survival despite lower P.,,, . Pa- 
tients ventilated with higher V,. which was associated 
with poorer survival, had higher P,,,, . Thus, arterial blood 
gas results may not be a good surrogate lor siir\i\al. 

In the ARDS Network study the plateau pressure for the 

low-V[ group was 26 

7 cm H-,0. Until recentlv. a 

plateau pressure < 3.'i cm H^O was conuiionl\ recom- 
mended. It is now reasonable to target a V , of 6 ml./kg 
predicted body weight and a plateau pressure < 30 cm 
H2O in patients with acute lung injury and ARDS. 

Is the (Joal of I'KKP to Raise the P„, so that 
the Fraction of Inspired Owfjen (an \W Decreased? 

This question brings us to the issue of physiologic ben- 
efits (sometimes called surrogate outcomes) such as blood 
gas values versus patienl-imporlant ouiconies such as sur- 
vival. As clinicians an important benefit of how we set the 
ventilator is the patient's blood gases. We have tradilion- 

Respiratory Care • September 2002 Voi 47 Nf) 9 


Mechanical Vkniilation Strategies: What's New and What's Worth Keeping? 

ally made \enlilator adJListincMls to improve the patient's 
blood gases. However, what is important for patients is 
whether they survive their acute respiratory failure. Most 
patients are not interested in their P,,o,. I suspect that few 
patients ask about their blood gases results, but they are 
very interested in whether they are likely to survive their 
mechanical ventilation course. 

There is an accumulating literature that suggests that 
P.,o, is not a good predictor of survival. The ability of a 
ventilator strategy to increase P,,j (and lower the fraction 
of inspired oxygen IF,,, |) may not be associated with 
improved survi\'al. Inhaled nitric oxide improves the P,,,, 
in most ARDS patients but does not affect survival." Mask 
CPAP in patients with acute hypoxemic respiratory failure 
improves P^q but does not affect the intubation rate or 
survival.** We know from the ARDS Network study that in 
ARDS patients higher Vy results in higher P^q , but sur- 
vival is better with lower V , .^- Prone positioning improves 
Pgo, in ARDS patients, but it does not affect mortality.''"* 

I submit that the reason to use PEEP in patients with 
acute lung injury is as part of a lung-protective strategy, 
rather than simply as a way that we can increase the P^g, 
and lower the F|q . Over 30 years ago Mead et al published 
data from a modeling study that showed that if an alveolus 
is open and a neighboring alveolus is collapsed, the pres- 
sure at the junction between the open alveolus and the 
closed alveolus can exceed 100 cm H,0 if the open alve- 
olus is inflated to 30 cm H^O.'' This suggests that col- 
lapsed alveoli adjacent to open alveoli can result in shear 
forces within the lung that could be injurious. Perhaps we 
can eliminate these high shear forces if we use an adequate 
amount of PEEP to maintain alveolar recruitment. 

There are classic data from Webb and Tiemey,^* pub- 
lished over 25 years ago. showing that if the lungs in a 
small animal model are ventilated with an inspiratory pres- 
sure of 45 cm H2O and no PEEP, much injury quickly 
occurs in the lungs. However, with the same inflating pres- 
sure and a PEEP of 10 cm H^O we can ameliorate much of 
the injury from the high inflation pressure. This suggests 
that PEEP might be part of a lung-protection strategy. 

What is an appropriate level of PEEP in patients with 
acute lung injury or ARDS? An appropriate level of PEEP 
is important, but evidence is lacking upon which to base 
firm guidelines for setting PEEP. Advocates of the open 
lung approach argue that high levels of PEEPshould be 
used to maximize alveolar recruitment." Those who ad- 
vocate strict adherence to the ARDS Network approach 
use the combination of PEEP and F,o^ that maintains the 
P^o^ between 55 and SO mm Hg (or a pulse-oximetry- 
measured oxygen saturation of 88-95%).^- A higher level 
of PEEP often, but not always, improves P^q,- Although 
there is considerable emotion associated with the appro- 
priate setting of PEEP, there is a lack of evidence that 

higher PEEP levels improve patient-important outcomes 
such as survival. 

In recent years there has been enthusiasm for the use of 
recruitment maneuvers to open the lungs. The rationale for 
this approach is that an open lung is part of a lung pro- 
tection strategy. A recruitment maneuver is a sustained 
increase in airway pressure, typically performed by in- 
creasing the ventilator's PEEP setting to 30-40 cm H^O 
for 30-40 seconds in an attempt to open collapsed lung 
tissue, after which a sufficient amount of PEEP is applied 
to keep the lungs open.""^ This generally has resulted in 
PEEP levels higher than what many of us have been ac- 
customed to using in our practice. A number of strategies 
have been reported as recruitment maneuvers.-"* including 
increasing the PEEP setting on the ventilator, sustained 
inflations, frequent sighs on the ventilator, ventilator modes 
that encourage spontaneous breathing, high-frequency os- 
cillation, and prone positioning. 

Some physiologic data suggest that recruitment maneu- 
vers and the open lung approach might be helpful. Lapin- 
sky et al'** reported that recruitment maneuvers improved 
arterial oxygen saturation, suggesting that that improve- 
ment was related to recruiting collapsed lung. There are 
computed tomography images showing much dependent 
collapse that improved after an aggressive recruitment ma- 
neuver.-"' However, other recent studies have questioned 
the benefit of recruitment maneuvers."" 

Although there has been a lot of enthusiasm about using 
lung recruitment maneuvers in ARDS patients. I submit 
that there is still a lot we need to learn about this. We do 
not know which are the best patients in whom to apply 
recruitment maneuvers. We do not know which technique 
is the best one to use. We do not know how we should set 
the PEEP after we do a recruitment maneuver. We do not 
know how to monitor the effect of recruitment. Most im- 
portant, we do not know the safety of these maneuvers. 
Although I have seen impressive P^q, increases with some 
patients after recruitment maneuvers. I have also .seen sub- 
stantial hemodynamic compromise and subcutaneous em- 
physema. We also do not know the effect of recruitment 
maneuvers on patient-important outcomes such as survival. 
The question that remains in relation to recruitment ma- 
neuvers and high levels of PEEP is whether open lungs are 
""happy" lungs or simply ""pretty" lungs. 

Are Nebulizers Superior to Inhalers 
During Mechanical Ventilation? 

A number of studies have reported that metered-dose 
inhalers (MDIs) deliver enough drug into the lower respi- 
ratory tract to produce a physiologic response."*- ■" In a 
group of COPD patients. Dhand et al"*"^ reported that as few 
as 4 puffs of albuterol from an MDI could achieve a sig- 
nificant reduction in airways resistance. In that group of 


Respiratory Care • September 2002 'Vol 47 No 9 

Mkchanic'al Vkntiiation Sir All (ill s: What's Niav and What's Wokiii Ki i pinci 








■ Delivered dose DAmount In urine 

^H ^H 

^H ^ 


MDI + spacer (5 puffs) MDI + right-angle adaptor 

Fig. 3. The relationship between technique of albuterol delivery and the amount of albuterol detected in the unne (a proxy for the amount 
of albuterol delivered into the lungs) in mechanically ventilated patients. Note that the metered-dose inhaler (MDI) with spacer is the most 
efficient, whereas the greatest absolute amount of albuterol is delivered by nebulizer. (Adapted from Reference 46.) 

patients, larger doses of 8 and 1 6 puffs of albuterol did not 
further reduce airways resistance. Marik et aF'" compared 
3 albuterol delisery approaches in intubated mechanically 
\entilated patients (Fig. 3). In one approach they used an 
MDI and spacer to deliver 5 puffs of albuterol. In another 
group they used the MDI with a right-angle adapter in- 
stead of a spacer. In a third group they used a nebulizer in 
the ventilator circuit. They measured the amount of albu- 
terol in the patients' urine, reasoning that the only way that 
albuterol could be present in the urine of an intubated 
patient is by what is deli\ered into the lower respiratory 
tract. They reported that MDI with spacer was the most 
efficient way of deli\ering albuterol into the lower respi- 
ratory tract: 38% of the dose was delivered into the lower 
respiratory tract. Using an MDI with the right-angle adapter 
in the ventilator circuit was significantly less efficient: 
only 97( of the dose was delivered into the lower respira- 
tory tract. The nebulizer was less efficient than the MDI 
with spacer: 16% of the nebulizer dose ended up in the 
lower respiratory tract. However, in tibsoliite terms, the 
nebulizer delivered more drug into the lower respiratory 
tract than either of the other 2 techniques. This is ex- 
plained by the very large dose of drug placed into the 
nebulizer cup. To summarize the Marik et al study, the 
most drug is deli\ered into the lower respiratory tract with 
a nebulizer, but the MDI with spacer is the most efficient 
way of deli\ering the drug. 

So how do I use these data in my practice? I believe an 
MDI is an acceptable way to routinely deliver bronchodi- 
lators in intubated mechanically ventilated patients. How- 
ever, with a patient who needs a large dose of j3 agonist, 
such as in a patient with acute severe asthma, a nebulizer 
may be a more efficient way of doing that. This could be 

achieved with an inhaler as well, but would require a lot 
more actuations from the MDI. 

Is Pressure Support a Simple Mode? 

Pressure support is a commonly used ventilation mode, 
and the common thinking is that pressure support is a 
relatively simple mode of mechanical ventilation. How- 
ever, if we closely examine the delivery of a pressure 
support breath, we see that this may not be the case. First, 
the patient needs to generate enough inspiratory effort to 
trigger the breath, because there is no backup rate on the 
ventilator. The trigger can be an issue with pressure sup- 
port, particularly in patients who have air trapping. Once 
the breath is initiated, the pressure rises from the baseline 
pressure (the PEEP setting) to the inspiratory pressure sup- 
port level. That rise in pressure, which is related to the 
amount of flow the ventilator puis into the circuit at the 
beginning of inspiration, can be very rapid or in other 
cases may be very slow. With the newer generation of 
ventilators it is possible to change the rate of pressure rise 
at the beginning of the pressure support breath (Fig. 4). 
Some evidence suggests that the ability to adjust the rise 
time during pressure support may be beneficial for some 
patients.-"-^" With pressure support it is also important to 
consider the cycle of the breath from the inspiratory phase 
to the expiratory phase. The breath should cycle to the 
expiratory phase v\ithoul the patient needing to actively 

Several studies have reported ihal the expiratory cycle 
in COPD patients can be problematic.^'^- Because of the 
high airways resistance and high lung compliance with 
COPD. the inspiratory phase may be very prolonged dur- 

Rf.spir.atory Carf • September 2002 Voi 47 No 9 















Slow Rise 

Moderate Rise 

Fast Rise 

/ — 

/» — 1 




i i 




























Time (s) 

Fig. 4. A feature available on new-generation ventilators is the ability to adjust the rise time during pressure support and pressure controlled 
ventilation. Note that the effect of an increase in rise time (the time required to reach the inspiratory pressure level) is to adjust the flow at 
the beginning of inhalation. This may be used to improve patient-ventilator synchrony. If the rise time is set very high, the pressure may 
overshoot the set pressure level. 

ing pressure support ventilation. As a result of the pro- 
longed inspiratory phase the patient will activate the ex- 
piratory muscles, so that a pressure spike in the circuit will 
result in termination of the pressure support breath. I sub- 
mit that this is not a desirable situation and represents a 
form of patient-ventilator dyssynchrony. The level of pres- 
sure support that we set may unload the patient's inspira- 
tory muscles, but may load the expiratory muscles because 
the patient needs to actively exhale. One of the ways to fix 
this problem with the newer generation of ventilators is to 
adjust the flow at which the ventilator cycles from the 
inspiratory phase to the expiratory phase (Fig. 5). 

Does the Endotracheal Tuhe Impose a Significant 
Resistance to Spontaneous Breathing? 

Many papers published over the last 20 years suggest 
that the endotracheal tube (ETT) imposes soiYie resistive 
load in the spontaneously breathing patient.^' ''^ These 
data have contributed to the practice of many clinicians to 
use low-level pressure support to compensate for the work 
of breathing through the tube.'*'''' On the newer generation 
of ventilators there is a mode called "tube compensation" 
designed specifically to compensate for tube resistance.''*- ''- 

How impoilant is this issue? A superficial review of these 
data indicates that an HTT increases the work of breathing. 

However, the effect does not become clinically important 
unless the minute ventilation is high (> 10 L/min) and the 
ETT size is very small. I interpret these data to suggest that 
the resistance to breathing through an ETT only becomes 
impoilant when the minute \entilation is very high, such as in 
a septic ARDS patient, whom we would not want to breathe 
spontaneously. Hovve\er. at reasonable minute ventilations of 
10-12 L/min I do not think that the issue is nciuiy as great as 
many of us have been led to believe. 

Fig. 5. During pressure support ventilation, the inspiratory phase is 
terminated when the flow decreases to a ventilator-set flow cutoff. 
In this example, the 25% flow cutoff results in a prolonged inspira- 
tory phase. When the flow cutoff is increased, the inspiratory time 
(and tidal volume) is decreased. 


Respiratory Care • September 2002 Vol. 47 No 9 

Mechanical ViiNTiiAiioN Strategies: What's New and What's Woriii Ki ipinc'; 








Fig. 6. Measurements of airway flow, airway pressure, inhaled and exhaled volume, and esophageal pressure in a patient being ventilated 
with synchronized intermittent mandatory ventilation. Note that the esophageal pressure swings (reflecting changes in pleural pressure due 
to respiratory muscle contraction) are nearly as great during the mandatory breath as during the spontaneous breaths. 

Although prolonged trials of spontaneous breathing 
through an ETT may add some additional load on the 
respiratory muscles, I do not think that this is a major issue 
tor a 3()-min to 2-hour spontaneous breathing trial. Es- 
teban et al reported similar outcomes for 2-hour sponta- 
neous breathing trials using low-level pressure support or 
aT-piece.^^ Straus et aP-* reported that the resistance through 
the ETT before extubation was similar to the resistance 
through the upper airway after extubation. This suggests 
that an unsupported spontaneous breathing trial may be the 
desired technique to determine whether the patient is likely 
to tolerate extubation. 

Is Synchronized Intermittent Mandatory Ventilation 
a Useful Weaning Mode? 

In a study addressing this question, Brochard et aP' 
screened patients for weaning readiness. If found ready to 
wean, the patient was placed on a T-piece for up to 2 
hours. The majority of patients tolerated the 2-hour spon- 
taneous breathing trial and were extubated. This is an im- 
portant finding: most patients did not need any weaning 
whatsoever: they needed somebody to pay attention to 
w hether they were ready to breathe on their own. The 25% 
of patients who did not tolerate the 2-hour spontaneous 
breathing trial were randomized to weaning by either syn- 
chronized intermittent mandatory ventilation (SIMV), T- 
piece. or pressure-support weaning. The greatest weaning 
success was with pressure-support weaning, and the worst 
was with SIMV. The important findings were that most of 
the patients did not need any weaning and SIMV produced 
the poorest weaning outcomes. 

A study by Esteban et aP" had a similar design. Again, 
patients were screened for weaning readiness. If a patient 
was found ready for weaning, the patient was placed on a 
T-piece trial for up to 2 hours. Again, most of the patients 
tolerated the 2-hour spontaneous breathing trial and were 
extubated. The 25% of patients who required weaning 
were randomized to T-piece trials, pressure support, or 
SIMV. This study found the greatest weaning success w ith 
T-piece trials. But. similar to the Brochard study. SIMV 
produced the poorest weaning outcomes. 

Both of the latter studies showed that most patients 
don't need weaning at all. And for patients who need 
weaning the worst outcomes occur with SIMV. Why is it 
that these studies found the poorest weaning outcomes 
with SIMV? Here is the reason I believe that occurred. 
During SIMV the patient's respiratory muscles contract, 
for all intents and purposes, just as hard during the man- 
datory breaths'''-'"* as during the spontaneous breaths (Fig, 
6). The original theory of SIMV was that the patient's 
respiratory muscles work on the spontaneous breaths and 
rest on the mandatory breaths, but in reality the patient's 
respiratory muscles may work just as hard on the manda- 
tory breaths as they do on the spontaneous breaths. There 
is abst)lutely no way that the patient's respiratory center 
can anticipate the breath delivery from the \entilator and 
modulate its output in aiiliciiiation of whether the breath 
will be a spontaneous bicalh or a mandatory breath. Ac- 
cordingly, SIMV — particularly low-rale SIMV — may not 
be much different than a prolonged spontaneous breathing 
trial and, even worse, iriay result in substantial patient- 
ventilator dyssynchrony. 

Respiratory Care • September 2002 Voi. 47 No 9 


Mkchankai. Vi-.ntu.ation Strategies; What's Ni:w and What's Worth Keeping? 

Are Weaning Protocols Safe and Kffective? 

This issue tiiat has rcceiscd a lot ot atlenlidii in rcccnl 
years. In reports by Ely et alj'' '*' respiratory therapists 
(RTs) assessed patients in a medieal/siirgical intensive care 
unit for weaning readiness, and based on the RT's assess- 
ment a decision was made whether to conduct a sponta- 
neous breathinj; trial, ll'tiie patient tolerated a 2-hour spon- 
taneous breathing trial, the RT reporteil the results to the 
physician. The result ot this I'orced interaction between the 
RT and the physician was a significant reduction in ven- 
tilator days, lower intensive care unit costs, and fewer 
complications. Other studies have also reported that RT 
protocols for weaning from mechanical sentilation are safe 
and effecti\e. Kollef et al*^- reported that a weaning pro- 
tocol resulted in weaning patients safely and more quickly 
than traditional physician-directed weaning. Marelich et 
al**' also reported that a weaning protocol resulted in fewer 
ventilator days and required no additional RTs to imple- 
ment the protocol — the RTs and the nurses were able to 
implement it directly into their moment-to-moment activ- 
ities within the intensive care unit. 

Do New Ventilator Modes Facilitate Weaning? 

AutoModi'. The proposed ad\anlage of AutoMode is 
automatic weaning from pressure control to pressiue sup- 
port and automatetl escalation of supporl as patient effort 
diminishes. The \entilator pro\ ides dual-controlled breath- 
to-brealh pressure-controlled \entilation if the patient is 
apneic. If the patient triggers 2 conseeiai\e breaths, the 
ventilator switches to breath-to-breath dual-controlled pres- 
sure support. If the patient again becomes apneic. the ven- 
tilator switches back to dual-controlled breath-lo-breath 
pressme-controlled ventilation. 

Tube Compensation. This mode is designetl lo compen- 
sate for endotracheal lube resistance \ia closeii-loop con- 
trol of calculated tracheal pressure. It uses the know n re- 
sistive coefficients of the artificial airway and nieasiuenient 
of instantaneous tlow to apply pressure proportional to 
resistance throughout the respiratory cycle. 

Proportional Assist Ventilation. This mode w as designed 
to increase or decrease airway pressure in proportiiin to 
patient effort. This is accomplished by a positive feedback 
control that amplifies airway pressure proportional to in- 
spiratory flow and voluine. and respiratory elastance and 
resistance are the feedback signals. 

In recent years a number of new ventilator modes have 
become available. These have recently been described in 
detail elsewhere'*'* ''^'^ and some of them are defined briefly 

Airway Pressure-Release Ventilation. With this mode. 
airway pressure is transiently released to a lower level, 
after which it is quickly restored to reinflate the lungs. The 
patient is allowed to breathe spontaneously at both levels 
of CPAP. Alveolar ventilation depends on lung compli- 
ance, airways resistance, the magnitude of the pressure 
release, the duration of the pressure release, and the mag- 
nitude of the patient's spontaneous breathing efforts. 

Dual Control Within a Breath. In this mode the venti- 
lator switches from pressure control to volume control 
during the breath. The proposed advantage of this ap- 
proach is a reduced work of breathing while maintaining 
constant minute volume anil V,. 

Dual Control Breath-to- Breath; Pressure Control. Ihis 
mode provides pressure-controlled ventilation with a constant 
minute volume. The level of pressure control is adjusted 
breath-to-breath to maintain a constant delivered Vy. 

Dual Control Breath-to-Breath; Pressure Support. Th i s 
mode provides pressure support ventilatii)n with a constant 
Vj. The pressure support level vaiies brealh-lt>-breath to 
maintain the V , constant. 

Although there is considerable clinical interest in this 
issue, there is presently only low-level evidence that any 
new ventilator mode facilitates weaning."'-'*'* This does not 
exclude the possibility that new ventilator modes may fa- 
cilitate weaning, but no high-level ev idence suggests that 
we are able to wean patients more quickly by using a new 
mode on the ventilator. This is in stark contrast to the 
evidence that the use of protocols can vv ean patients more 
quickly. I believe that a skilled clinician at the bedside 
does more to facilitate venlilati>r weaning than any venti- 
lator mode. Liberation fiom the ventilator is about assess- 
ment of patients for mechanical ventilation discontinua- 
tion potential and conducting spontaneous breathing trials. 
Moreover, the constraints (rules) placed on the use of anv 
"weaning" mode may complicate ventilator discontinua- 
tion and prolong the weaning piocess. 


For new advances in mechanical ventilation and new 
ventilator strategies, we do need to consider costs. Strat- 
egies that av oid intubation and get patients extubalcd sooner 
decrease costs related to mechanical venlilalion. .Second, 
"people" solutions such as weaning protocols are gener- 
allv better than "lechnology" siilutions such as new ven- 
tilator modes. Third, mechanical ventilation is supportive; 
it is not cmative. In fact, it has the potential to do harm, as 
we have learned from the ARDS Network trial. We need 
lo be careful aboul the follies of focusing on short-term 


Respiratory Care • September 2002 Voi 47 No 9 

Mechanical Vhntu.ation Stratugils: Whai's Ntw and Whai's Woriii Kiumnci? 

physiologic oulcomcs such as inipro\eci Dxygenation. As 
cHnicians we like to do things that mai<e tlie patient's 
bkiod gases better, but there are a number of examples in 
v\ hich blood gases are not related to patient-important out- 
comes such as survival. As we see new advances in me- 
chanical ventilation, a question we need to ask ourselves is 
whether these are solutions for problems or whether these 
are simph' solutions in search of problems. 


I uiHild like 111 thank all oIiIk' respiratory therapists, critical care lellows. 
and residents who ha\e. da_\ alter da> and year alter year, asked me the 
really tough (.(iiestions that ha\e helped me to form many of the ideas thai 
I have shared in this paper. 


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Respir.atory Care • September 2002 Vol 47 No 9 



Lullers addressing topics ol currcni inicrcst or rnaicrial in Rfspiratorv Cari will be considered tor publication. The Editors may accept or 
decline a letter or edit without changing the author's views. The content of letters as published may simply relleet the author's opinion or 
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It Hiirt.s to Say "Hertz" 

There i.s a new virus going around 
that affects only respiratory therapists. 
It seems to affect the brain's speech 
center in a curious way. I have ob- 
served signs of it in my own depart- 
ment and in 3 abstracts I just reviewed 
for this year's Open Forl'm at the In- 
ternational Respiratory Congress. Like 
the herpes virus, this new strain seems 
to he dormant for periods and then 
becomes active when the therapist 
starts talking about high-frequency 
ventilation ( HFV ). Therapists will start 
listing the ventilator settings and all 
of a sudden lapse into an incongruity. 
They will say something like this: "The 
mean airway pressure was 12," mean- 
ing the average pressure was 12 cen- 
timeters of water. Then they will say, 
"The amplitude was 35." meaning that 
the difference between the peak and 
trough airway pressure was 3.5 centi- 
meters of water. Then all of a sudden 
they start to stutter, turn pale, dia- 
phoretic, and say the most inane thing: 
"The hertz was 10." Then they recover 
immediately and say something like 
"The oxygen concentration was 60%." 
Fascinating! This virus causes them 
to momentarily confuse a unit of mea- 
surement (hertz) with a ventilation pa- 
rameter (frequency). What could be 
the etiology of this new virus? This 
time we cannot blame the ventilator 
manufacturers, because they clearly la- 
bel their controls as "Frequency" or 
"HFV rate." Perhaps it is due to prac- 
ticing unsafe ventilator checks. 1 fear 
this will become endemic and lead to 
even further lapses in awareness. I 
have a name for this new disease: 
parametometric inversosis. 

Watch out! 

Robert L Chatburn RRT FAARC 

Respiratory Care Department 

Department of Pediatrics 

Case Western Reserve University 

Cleveland, Ohio 

Clinician Perspective on Critical 
Thinking and Decision-Making 

1 ha\e been a registered respiratory 
therapist for 18 years, with 14 of those 
in positions in v\hich critical thinking 
(CT) and appropriate, accurate deci- 
sion-making (DM) are of paramount 
importance. In those positions an in- 
dividual either possessed CT and DM 
skills and survived or did not possess 
them and did not survive. After read- 
ing the editorial and original contri- 
bution on this subject in the May 2002 
issue,'- I think some clinician views 
about CT and DM should be presented. 

From my observations. CT and DM 
are skills. They must be practiced, 
tested, and refined in order to grow. I 
honestly believe they cannot be taught. 
Individuals can be exposed to them 
and then be placed in situations where 
they must be used. Depending on the 
individual, these situations will either 
make them or break them. All too of- 
ten 1 have seen individuals graduate. 
work a little, pass the registry, and 
think they have arrived: they are now 

I am intrigued by Or Mishoe's state- 
ment regarding the luxury of assess- 
ment of CT proficiency as an accep- 
tance criterion. Would this be 
prohibitive from a time or numbers 
standpoint? Isn't the crux of CT and 
DM an improvement in quality'.' 

1 do not think the environment of 
health care as it exists today fosters 
the growth and use of CT and DM. 
Task orientation seems to be in the 
forefront. Facilities must return to 
placing a premium on CT and DM in 
order for them to he fully appreciateil. 
Evidence showing that these 2 skills 
impact reducing costs and length of 
stay would be most beneficial. 

Whatever the reasons. 1 am afraid 
CT and DM are becoming a lost art. 
But then again I may be wrong. If 
T-piece trials can come full circle to 

be acceptable, maybe other useful 
practices are not far behind. 

Glenn A Roberts RRT 

Respiratory Care Services 

Medical Center of Central Georgia 

Macon. Georgia 


1 . Mistioe SC. Educating respiratory care pro- 
fessionals: an emphasis on critical think- 
ing. Respir Care 2002;47(5):568-569. 

2. Hill TV. The relationship between critical 
thinking and decision-making in respira- 
tory care students. Respir Care 2002:47(5): 

Is Critical Thinking a Luxury? 

I wish to respond to Dr Thomas 
Hill's study of critical thinking (CT) 
and decision-making (DM) in respira- 
tory care students' and Dr Shelley 
Mishoe's related editorial, which 
appeared in the May 2002 issue of 
Respirator-i Care.- 

I applaud Dr Hill's work and ap- 
preciate seeing research on respiratory 
care education appear in a professional 
journal, because this is such an impor- 
tant topic and there is so little research 
reported on it. I find Dr Hill's report a 
credible, challenging study, which 
adds to what we know of training re- 
spiratory therapists (RTs). He thor- 
oughly addresses many of the difficul- 
ties and limitations of this type of 
research. I agree with his suggestions 
for further reseiu-ch on the subject. 

The article reports a statistical cor- 
relation between students' CT capac- 
ity and their DM scores on the Na- 
tional Board for Respiratory Care 
Clinical Simulation Self-Assessment 
Examination. Dr Hill concludes that 
respiratory care educators should in- 
vestigate and adopt strategies to de- 
velop CT in students and recommends 


Ri;spiRAT()Rv Care^ • September 2002 Vol 47 No 9 


CT assessment as part of the evalua- 
tion process tor prospective students 
( and taculty ). My response is in 3 parts. 

Dr Hill's study measures DM usinj; 
the DM score of the National Board 
for Respiratory Care Clinical Sinuila- 
tion Self-Assessment Examination. 1 
am doubtful that the DM score from 
that exam actualls reflects DM capac- 
il\ in the puie sense, and whether thai 
exam score iruls measures the stu- 
dent's DM is not addressed in Dr Hill's 
study. That is. the score is labeled de- 
cision-makini:. but probabh reflects 
other factors. 

A basic conclusion of Dr Hill's 
study is that better CT proficiencx is 
related to better DM and that respira- 
tory care traininji programs are incor- 
porating teaching strategies that pro- 
mote CT. But data reported in the study 
seem to contradict the effectiveness 
of CT teaching strategies. I am skep- 
tical that CT can be instilled in stu- 
dents who are not endowed with it on 
admission and doubtful that respira- 
tory care instructors meaningfully im- 
prove CT in their students. Dr Hill's 
Table 4 is. I believe, mislabeled as 
"Strategies Used by Programs to De- 
velop Critical Thinking and Decision- 
Making." More accurately, those are 
used to iiuciupt to dexelop CT and 
DM. as it has not been established that 
any of them are effective or that there 
is a connection between them and stu- 
dent CT. 

1 do not share Dr Mishoe's convic- 
tion that Socrates would be pleased 
w ith the efforts tow ard problem-based 
learning, particularly in the respiratory 
care training industry, but 1 agree with 
Dr Hill that CT assessment should be 
added to the evaluation procedure for 
student applicants. 

I . The Decision-Making Measure 

It was my pleasure to ha\e served 
as a moderator of the American As- 
sociation tor Respiratory Care's an- 
nual "Sputum Bowl" from 1982 
through lyys. Early on it became clear 
that there is a startling fact about the 
subject content of respiratory care: 
there are a finite number of unique 

c|uestions and that number is quite 
small. This means that credentialing 
exam questions, like Sputum Bowl 
i.|uesiions. are variations and restate- 
ments of a limited number of items. 
Smularls. 1 believe that there are a 
limiicti number of possible decisions 
that can he used to construct branch- 
ing-logic clinical simulations in respi- 
ratory care. This unsettling insight 
came from my experience writing, ed- 
ilmg. and publishing computer-man- 
aged clinical simulations for the field 
of respiratory care. What is scored and 
reported as DM may be rote applica- 
tion of a small set of "IF. . . THEN" 
rules. For example: 

IF hypercapnia. THEN increase al- 
veolar minute ventilation. 

IF arterial resting Pq, is < XX mm 
Hg. THEN prescribe home oxygen. 

IF forced expiratory volume in the 
first second improves X'/f . THEN ad- 
minister bronchodilator. 

Such "IF. . . THEN" rules can be 
memorized. Although 1 have not at- 
tempted to identify and count the 
unique DM elements in clinical sim- 
ulations. 1 suspect that that number is 
small. The same items, rewritten and 
restated, appear again and again. The 
point is that there is reason to doubt 
that a high DM score on a clinical 
simulation exam authentically reflects 
DM capacity. It may. but it may also 
reflect simple familiarity with the 
topic, memorization of a few prob- 
lem-soh ing rules, and mastery of the 
gamesmanship element of branching- 
logic simulations. 

When simulations were adopted for 
respiratory care credentialing exams, 
they were promoted as instruments 
simulating the clinical environment, 
with opportunities to both make and 
rectify clinical decisions. Early exams 
w ere complex, w ith multiple true path- 
way branches. The current generation 
of simulations appears to be very 
nearly linear — merely strings of mul- 
tiple-choice questions. 1 wnnder if 
there has been a degrading of the meth- 
odology over the years and whether 
any measurement of DM skill has been 

diluted. I would like to see the same 
study using a generic measure of DM 
capacity in addition to the Clinical 
Simulatiidi Self-Assessment Exami- 
nation scores. Would not DM capac- 
ity be evident in an unfamiliar con- 

Di Hill's study attempts to address 
DM but does not recognize that the 
most any exam or simulation can do. 
necessarily removed from the clinic. 
is measure not clinical DM but the 
potential for clinical DM. Instruction 
designers and simulation developers 
know very well that there is a gap 
between exam performance and work- 
place performance.' Clinical decision 
situations rarely present as carefully 
worded multiple-choice questions. 
Moreover, that a student has DM ca- 
pacity, revealed by examination, does 
not indicate that the student will choose 
to apply it as a practitioner. Therefore 
1 cannot agree with the exact wording 
of Dr Hill's conclusion that, "students 
with strong CT proficiency make bet- 
ter clinical decisions." They seem to 
make better siimilated clinical deci- 

2. Teaching Critical Thinking 
Dr Hill's study surveyed respiratory 
care program directors to identify 
teaching strategies used to develop CT. 
The study lists as many as 9 such strat- 
egies used in various combinations and 
(1 presume) to various degrees, in the 
10 programs participating in the study. 
But, as Dr Hill states, those strategies 
are merely puipcftcd to improve CT, 
It has apparenilv not been established 
that any of them significantly improve 
CT. A study of baccalaureate nursing 
programs found no increase in student 
CT abilitv from sophomore to senior 
years, but did find CT improvement 
as a result of clinical experience after 
graduation. ' This perhaps suggests that 
respiratory care training programs 
might improve CT by redesigning and 
refilling clinical instruction to authen- 
ticalK mirror the clinic and by con- 
centrating on higher-level assessment 
and management skills rather than 
technical procedures. It would be use- 

Respir.atory C.\re • September 2002 Voi 47 No 9 



fill to stud) CT aiiUMiL; praclii-'iiii; KTs. 
The stud> by Maynaicl^ also questions 
the validity ot the Watson-dlaser Crit- 
ical Thinking Appraisal instrument 
(used in Dr Hill's study! tor the field 
of nursing and notes the difficulty of 
even defining CT so that it can be 
measured. No relatie>nship was found 
between CT and nursing competence, 
leading the researcher to ask if nurs- 
ing practice is too prescriptive to per- 
mit true, reflective, open-ended CT. 
The same question may be asked of 
respiratory care. Much of what we la- 
bel CT and DM may be merely a sort 
of respiratory care catechism, tightly 
defined and finite. 

Most troubling is Dr Hill's report 
that, "No significant differences were 
found in the CT scores of students in 
different programs." As there is wide 
variation in the CT strategies em- 
ployed by the schools in Dr Hill's 
study, should we not expect to see dif- 
ferences in the CT measurement in 
graduating students between the pro- 
grams'? Are all of these strategies, in 
any combination, equally potent? 
More likely, 1 suspect, they are equally 

3. Socrates 

In the case of the respiratory care 
training industry. I cannot agree with 
Dr Mishoe's perception that Socrates 
would be pleased with efforts toward 
incorporating problem-based learning. 
It is my perception that Dr Hill is cor- 
rect in stating that "programs have ex- 
perimented' w ith strategies to improve 
CT, such as problem-based learning. 
The dominant instruction method in 
respiratory care education is lecture. 
The statement that. "Educators today 
are well trained. . . in the theories of 
instructional planning, delivery, and 
evaluation" does not agree with my 
experience or perception. My percep- 
tion is that respiratory care educators 
teach as they were taught — by talk- 
ing. Dr Hill's study reports only 4 of 
the 10 programs surveyed use prob- 
lem-based learning, and those data are 
self-reported. I recall a program direc- 
tor who responded to the Dean's plea 

for attention to CT by delivering a 
lecture on CT. Socrates might smile 
that as educators we believe that we 
have the capacity to improve CT in 
others by employ mg teacher-centered 
methods, without directly and aggres- 
sively addressing CT as an instruc- 
tional goal. 

Socrates is admired for tenaciously 
drilling to the tiuth. debunking un- 
founded assumptions, and rankling 
those in power by revealing their self- 
interest and collective ignorance (he 
included himself in this). He came to 
a bad end. 1 wonder how Socrates 
would fare were he reborn today as a 
respiratory care educator. I suspect his 
outcome might be the same. He might 
point out that the respiratory care train- 
ing industry fails the field of respira- 
tory care for reasons of self-interest. 
He would reveal our collective self- 
delusion when we devise a sophisti- 
cated testing method to verify clinical 
DM acumen, then sabotage it by 
shamefully spoon-feeding and drilling 
students so that they may pass creden- 
tialing exams. When we indulge in 
intensive exam preparation in our 
programs (sometimes as much as a 
semester of the course), we deceive 
ourselves that improved DM scores 
e\idence CT. 

In one personal respiratory care 
teaching experience, the Dean forbade 
us to "teach to the exam." as this is 
patently unethical. Across the field of 
respiratory care, however, that pro- 
scription is the exception. Some edu- 
cators point proudly to their program's 
pass rates, ignoring that the statistical 
validation methodology the exams are 
based on does not include exhausti\ ely 
drilling candidates, using mock and 
even retired exams, rendering the en- 
tire process suspect, if not corrupt. A 
program's central goal ought to be gen- 
erating safe and competent practitio- 
ners. An obsession v\ ith high program 
pass rates is a different goal and serves 
the self-interest of programs, institu- 
tions, and educators. I am convinced 
that an intelligent student can be 
schooled and drilleil to pass our cre- 

dentialing exams without substantive 
clinical experience. This is the di- 
lemma public schools face when po- 
litical pressure iiioli\ ates them to teach 
students to score well on standardized 
tests rather than actually teaching the 
students. I am also convinced that dril- 
ling students in clinical simulation 
exam strategy is highly effective in 
improving DM scores, falsely improv- 
ing CT and clinical DM. 

Most troubling to me is si>mething 
evoked by Dr Mishoe's statement that. 
"1 do not think we have the luxury at 
present of imposing additional accep- 
tance criteria for admissions into our 
programs." Is CT capacity a luxury in 
RTs? Should we take this to mean that 
it is in our power to instill CT think- 
ing in students in whom it does not 
exist, or that CT isn't really impor- 
tant? I disagree with both. There is 
perhaps reason to hope that CT can be 
nurtured and refined where it already 
exists but no evidence that CT can be 
taught to low-caliber students. Dr 
Hill's study and Dr Mishoe's editorial 
declare the vital importance of DM in 
RTs and identify CT as an essential 
element in DM. That double message 
is evocative of a frightful willingness 
in respiratory care programs to soften 
acceptance criteria so that classrooms 
may be filled. Lowering standards to 
fill the student ranks serves only the 
.self-interest of programs. Worse, pa- 
tients are unknowingly placed at risk 
by exposing them to clinical students 
who should not have been accepted. 1 
believe that now, more than ever, re- 
spiratory care needs to hold to its stan- 
dards. We don't need just bodies in 
the classrooms and clinics: we need 

The crucial factor in generating 
competent and safe RTs is the quality 
of incoming students. Dr Hill's study 
\erifies exactly that, reporting a pos- 
itive correlation between GP.-\ and CT. 
Carpenters know that no degree of 
craftsmanship compensates for poor- 
quality materials. Filling the ranks w ith 
unqualified students may keep pro- 
grams atloat but ultimatelv dishonors 

1 020 

Re.spir.\tory Care • September 2002 Voi_ 47 No 9 


the field and delays resolving the es- 
sential obstaele to recruiting — poor 
salaries. When the demand lor skilled 
RTs is suttieient to increase wages, 
students ot qualits will be attracted. 
The current crisis in student recruit- 
ment, unlike previous downswings in 
the cycle, is not responding to a slug- 
gish economy. This is alarming. Po- 
tential candidates seeking a career 
change are passing over respiratory 
care because, among other factors, it 
does not pay well. Dr HilTs study sug- 
gests that the field is failing to attract 
or keep male students. Perhaps this 
should be examined. I agree with the 
suggestion that prospective faculty be 
tested for CT. but further recommend 
that current faculty be evaluated as 
well. 1 would not presuppose that re- 
spiratorv care faculty are endowed 
with CT skill, and 1 suggest this as a 
starting point if CT is to be addressed 
in students. .And the apparent gap be- 
tween the best interests of the field 
and the schools deser\es some critical 

Keith B Hopper PhD RRT 

Technical Communication Program 

Southern Polytechnic State 


Marietta, Georgia 


1. Hill TV. The relationship between critical 
thinking and decision-making in respira- 
tory care students. Respir Care 2002:47(5): 

2. Mishoe SC. Educating respiratory care pro- 
fessionals: an emphasis on critical thinking 
(editorial). Respir Care 2()()2:47(5):56S- 

3. Smith PL and Ragan TJ. Instructional de- 
sign. 2nd ed. New York: John Wiley & 
Sons. 1999, xv, 399. 

4 Maynard CA. Relationship of critical think- 
ing ability to professional nursing compe- 
tence. J Nurs Educ 1996 35( I2):12-18. 

Dr Hill replies 

1 appreciate Dr Hopper taking the 
time to respond to the report of my 
research on critical thinking ICT) and 

decision-making (DM) in respiratory 
care students. My goal, as Dr Hopper 
points out, was to add some e\ idence 
to what we know about training respi- 
ratory therapists, by looking at the re- 
lationship between the CT and DM 
constructs, while recognizing the re- 
strictions and limitations imposed by 
the study design. One of my doctoral 
professors always reminded us that we 
didti't have to rediscover the atom but 
tnerely add a grain of sand to the moun- 
tain of knowledge. It is the constant 
addition of those mere grains that, 
when taken collectively, begin to re- 
\eal the important discoveries. Our 
best chance of improving the educa- 
tion of respiratory therapists will come 
from the summation of many such 

In attempting to measure a com- 
plex construct such as DM. the re- 
searcher seeks to identify an instru- 
ment that will capture the essence of 
that construct. Dr Hopper points out 
that the National Board for Respira- 
tory Care Clinical Simulation Self- 
Assessment Examination may reflect 
factors other than DM, and that may 
be so. 1 chose to use that instrument as 
a tneasure of DM because the partic- 
ipating programs were already using 
it and it also allowed me to compare 
my data to that reported by other re- 
searchers. I agree with Dr Hopper's 
suggestion that, "students with strong 
CT proficiency make better simulated 
clinical decisions," since the study was 
performed using clinical simulation 
exams and not direct observation of 
clinical performance. Measuretrient of 
DM in the clinical setting is an excel- 
lent suggestion for further research. 

Dr Hopper is skeptical that CT can 
be instilled in students who are not 
endowed with it upon admission to a 
program, and Mr Roberts makes the 
same point. 1 don't disagree with their 
statements; however, 1 think educa- 
tional progratns nevetlheless have an 
obligation to try to develop CT profi- 
ciency in students. By providing a 
learning cn\ironment in which CT is 
modeled, encouraged, and evaluated, 

students may have an opportunity to 
learn CT. 1 agree that nol all students 
will be highly proficient in CT upon 
graduation, btit we should still strive 
to encourage all students to develop 
this itnportant skill. 

1 would also like to cotnment on Dr 
Hopper's reduction of branching logic 
clinical simulations to a series of 
"IF. . . THl-N" rules. Consider Dr 
Hopper's first example, that of increas- 
ing alveolar minute ventilation in the 
face of hypercapnia. There are several 
factors the practitioner must consider 
before changing the ventilator settings. 
Does the patient have chronic carbon 
dioxide retention secondary to chronic 
obstructi\e pulmonary disease? Is a 
small degree of hypercapnia tolerable 
(the permissive hypercapnia approach 
to ventilation)? Should tninute venti- 
lation be increased by changing the 
tidal volume, the frequency, or both? 
My experience with clinical simula- 
tion examinations has taught me that 
it is consideration of such additional 
factors that separates the successful 
test-taker from the unsuccessful one. 
Consideration of all those factors and 
a careful e\ aluation of the merits and 
perils of treatment options start to re- 
semble the definition of CT. 

Dr Hopper's interest in this study 
and it's itnplications for respiratory 
care education are much appreciated. 
It is through this type of dialog that 
we all learn how to do a better job of 
preparing future practitioners. 

Thomas V Hill PhD RRT 

Department of Respiratory Care 

Kettering College of Medical Arts 

Kettering. Ohio 

Dr Mishoe replies 

In response to the letters from Dr 
Hopper anil Mr Roberts. 1 restate that 
I question whether any respiratory 
therapv program should require the 
Watson Cdaser Critical riiiiiking Ap- 
praisal (WGCTA) as patl of its appli- 
cation process anti criteria for admis- 
sion. Icannotjustify the cost, the effort. 

Respir.atory Care • September 2002 Voi 47 No 9 



or the L'oiisequeiK'es of adding more 
admissions criteria during a time of 
low applicant pools in respiratory care. 
My opinion that we do not have the 
luxury of adding additional admissions 
criteria such as the WGCTA in no way 
implies that critical thinking (CT) is a 
luxury we cannot afford. The prospec- 
tive student pool is small ent)ugh. with- 
out restricting it further; that is my point, 
pure and simple, with no other agenda 
attached, as Dr Hopper suggests. 

If someone does not agree with that 
opinion, then I would ask for reasons 
they might offer as to ( 1 ) why we 
should add the WGCTA as part of the 
admi.ssions criteria. (2) how we would 
use WGCTA scores in oin- student se- 
lection process, and (3| how we would 
explain turning away a student with 
acceptable GPA and other admissions 
criteria but unacceptable WGCTA 
scores. I would seriously question Dr 
Hopper. Mr Roberts, or anyone in- 
volved in education today to turn away 
a qualified, prospective student with ac- 
ceptable admissions criteria because of 
a WGCTA score. This is not to say that 
we should accept low-quality students 
or weaken our admission processes. 

I will not respond to other ques- 
tions in Dr Hopper's letter ("/.v CT 
capacity a luxury in IrcspiniUiry rlier- 
cipists] RTs'.' Should we tal<e this to 
menu that it ;.s //; our power to instill 
CT thinkinfi in siudcnis in whom ii 
does not exist. <n- that CT isn 't really 
important'.'"), because both statements 
are his. not mine. It is an interesting 
tactic to make your own statements 
and then argue against them in an at- 
tempt to assign ownership to someone 
else. We know what .Socrates would 
do when faced with similar circum- 
stances; he would require the person 
to provide clarification and give rea- 
sons to support any conclusions. 
Therefore I ask Dr Hopper how he 
made the leap from "We do not have 
the luxury of adopting the WGCTA to 
our admissions criteria" to "CT isn't 
really important." I do not follow the 
losiic in makini: such an association. 

The most troubling part of Dr Hop- 
per's letter is the implicatiiin that Dr 
Hill or I would suggest that we should 
fill classes with low caliber students. 
He wrote: "Dr Hill's study and Dr 
Mishoe 's editorial declare die vital im- 
portance of DM in RTs cnul identify 
CT as an essential element in DM. 
That double messat^e is evocalive of a 
frif>htfil willini^iu'ss in respirnlory 
care programs to soften acceptance 
criteria .so thai classrooms uuiy be 
filled." Anyone who knows me or my 
work understands that I have been a 
strong advocate for facilitating CT in 
respiratory therapy students, faculty, 
and clinicians. '^■' I ask Dr Hopper to 
explain why he sees a double message 
and how he draws his conclusions. 
Again, I do not follow his logic and 
find no rationale to support how he 
came to such a conclusion. 

I understand that editorials and let- 
ters to the editor allow for much more 
opinion than a discussion in an origi- 
nal study. However, I believe we 
should always strive to provide rea- 
sons and evidence to explain and sup- 
port our opinions. I also teach students 
that, when they make statements that 
are not within conventional wisdom 
taken to be fact, theory, or common 
practice, they make it explicit that it is 
their opinion. Consequently, I am con- 
cerned with Dr Hopper's comments 
about the changing nature of the clin- 
ical simulation exams ("Early exams 
were comple.x, with multiple true path- 
way branches. The current i>enerarion 
of simulations appears to be very 
nearly linear — merely slrinfis of nuil- 
liple-choice questions. I wonder if 
there has been a degrading of the nwth- 
odology over the years and whether 
any measurement of DM skill has been 
diluted.") or any relationship to the 
Sputum Bowl. 1 object to someone stat- 
ing that there has been a degrading of 
any standardized exam based on per- 
sonal impressions that the nature of 
the exam is somehow different. Again, 
I would ask Dr Hopper to indicate that 
these are his own opinions and then to 
show the data to support his opinions. 

I3r Hill's paper is not intended as a 
\alidatu)n of either the clinical simu- 
lation or the WGCTA; that was not 
the purpose of the study. ^ Rather, the 
purpose was to determine if there is a 
relationship between decision-making 
in respiratory care (as measured by 
the clinical simulation exam) and gen- 
eral CT (as measured by the WGCTA). 
I believe Dr Hill chose appropriate in- 
struments to test his hypothesis. Any 
instrument chosen to measure any vari- 
able has limitations, whether that instru- 
ment is the WGCTA or the decision- 
making section of the clinical simulation 
exam. To conduct research you must 
make a decision as to how you will mea- 
sure soinething and then you must state 
and accept the method's limitations, 
assumptions, and margins of error. 
There is quite a difference between 
choosing an instrument as a measure- 
ment tool and developing or \alidat- 
ing an instrument. Dr Hill's study did 
not assess either the methodology for 
development of the clinical simulation 
or any changes in the instrument from 
previous versions. Therefore I do not 
follow why Dr Hopper has offered his 
opinions about the clinical simulations. 

I do not understand how the Spu- 
tum Bowl or its questions fit with Dr 
Hopper's letter. Who ever claimed that 
the Sputum Bowl is a reflection of 
practice in respiratory care? When has 
any association been inade between 
the Sputum Bowl and practice, the 
Sputum Bowl and credentialing ex- 
ams, or the Sputum Bowl and CT? 
Factual, short answers such as 
deiTionstrated in the Sputum Bowl are 
not a reflection of CT and do not fit 
with this discussion. In my opinion 
the Sputum Bowl is a chance to have 
some fun while flaunting RT trivia, 
facts, figures, and concepts; no more 
and no less. 

I do agree with Dr Hopper on the 
point he makes about the dilferences 
between "teaching to a test" and fa- 
cilitating CT. Novices need both. A 
responsible program in any discipline 
must prepare its students for practice, 
and that includes their ability to pass 


Ri;,spiR AToi-tY Care • September 2002 Voi, 47 No 9 

Li I ii.Ks 

credentialing exams. Hdwcver, wo 
should iu)t stop there. As Dr Hill stales, 
lurthei" researeh is needed to determine 
which educational methods can best 
enhance CT.^ Dr Hill's stud\ describes 
the current strategies used by the pro- 
grams in his study but lacks the data 
to draw any valid conclusions about 
those strategies. Therefore, no mean- 
ingt'ul discussion is possible. Although 
Dr Hopperaiul perhaps Socrates woukl 
not be pleased with efforts to inci>r- 
poratc problem-based learning. I can 
iiffer some data that suggest that prob- 
lem-based learning can enhance respi- 
ratory therapy students" general CT. 
as measured by the WGCTA." The 
literature on problem-based learning 
offers many examples, some of them 
cited in my editorial, on the successful 
use of this method to improve students' 
performance, including their CT. 

I believe that the best way to facil- 
itate CT in students and others is to 
role model it through a combination 
of skills, dispositions, and opportuni- 
ties in the practice setting. Faculty and 
clinicians should serve as mentors to 
students and demonstrate the abilities 
to prioritize, anticipate, troubleshoot. 
decide, communicate, negotiate, and 
reflect.' '' Some of these abilities can 
be facilitated and even measured by a 
test, but many occur in the practice 
setting. Faculty and practicing RTs can 
role model CT by showing an appre- 
ciation for multiple perspectives and 
being able to articulate how they de- 
rive their conclusions. I believe an ev- 
idenced-based approach to practice 
can enhance CT in respiratory prac- 

tice as well as miprove certain patient 

I agree with Mr Roberts that CT 
must be practiced, tested, refined, and 
expected in order to grow. 1 agree that 
CT skills and attributes can be facili- 
tated in educational programs, but it is 
in practice that these skills will fur- 
ther de\ clop and can be enhanced. My 
own research supports Mr Roberts' 
opinion that individuals can be ex- 
posed to CT skills and then must be 
placed in situations to use those skills 
for CT to noinish.' 1 strongly agree 
w ith Mr Roberts that CT is a lost art if 
the practice setting does not expect it 
or support it. Research that I conducted 
indicates that practicing RTs who dem- 
onstrate high levels of CT have spe- 
cific skills and attributes and work in 
organizational settings that support 
it.' " Administration, including the de- 
partment director and medical director, 
play an impoilant role in establishing 
organizational cultures that facilitate CT 
in respiratoiy care practice.'" 

Education programs and continuing 
education can enhance CT skills and 
traits, but ultimately it is where RTs 
work that will determine if CT is used 
by those capable of performing at the 
highest levels. 1 truly hope that CT in 
respiratory care practice will flourish 
rather than become a lost art, as Mr 
Roberts warns. 

Shelley C Mishoe PhD RRT 

School of Allied Health Sciences 

Medical College of Georgia 

Augusta, Georgia 


I Misluic .SC ililnkinj; in rcspiraliiry 
care praclice. In: Mislioc SC. Welch MA 
Jr. Critical lliinking in respirutury care: a 
priiblem-haseil leainin}; approach. New 
York: McGraw Hill. 2(102. 

2. Ml^hoe .SC. MacliUyre NR, |-!\panding pro- 
fessional roles for respiratory care practi- 
tioners. RespirCare I997.42( I ):7I-9I. 

3. Mishoe SC. Critical thinking and problem 
based learning. In: Hess DR, Maclnlyre N. 
Mishoe SC. Galvin WF. Adams AB. Sa- 
posnick AB. editors. Respiratory care prin- 
ciples and praclice, Philadelphia: WB Saun- 
ders. 201)2. 

4. Mishoe SC. Hcinlen K, Health care trends 
and the evolving role of ihe respiratory care 
professional. In; Hess DR. Maclnlyre N. 
Mishoe SC. Galvin WF, Adams AB. Sa- 
posnick AB. editors. Respiratory care prin- 
ciples and praclice. Philadelphia: WB Saun- 
ders. 2002. 

."i. Hill TV. Ttie relationship between cntical think- 
ing ;uid decision-making in respiratory cire stu- 
denls. RespirCare 2()02;47(.';):.S7 1-577. 

6. Mishoe SC. Dennison FH. Goodfellow LT. 
Can respiratory therapy education improve 
critical thinking? (abstract) Respir Care 
1997:42(1 1):I078. 

7. Mishoe SC. Critical thinking in respiratory 
care praclice. PhD diss. Department of 
Adult Education. University of Georgia. 
Athens. Georgia, 1994. 

8. Mishoe SC. Critical thinking in respiratory 
care practice. Proceedings of the 35th An- 
nual Adult Education Research Conference. 
University of Tennessee. Knoxville. Ten- 
nessee. 1994:276-281. 

9. Mishoe SC. Critical thinking in respiratory 
care praclice (abstracl). Respir Care 1996; 

10. Montori VM.GuyattGH. What is evidence- 
based medicme and u hy should it be prac- 
ticed' Respir Care 2001 ;46l I I i: 1201- 

1 1 . Mishoe SC. The effects of institutional con- 
text on critical thinking in the workplace. Pro- 
ceedings of the 36th Annual Adult Eyjucalion 
Resciirch Conference. University of Alberta. 
Edmonton, Albeila. 1995:221-228. 

Respir.atorv Care • September 2002 Vol, 47 No 9 


Kt*\ifus "I Itnuks iitu\ OlIuT Midia. Noic in piihlishcrs Send icmcw copies ot hooks. Iilms. 
liipcs. and sotiwarc lo R(.hi'ik.\ruK^ Cakk. 6(K) Ninth Avenue. Suite 702. Seattle WA 98104. 

Books, Films, 
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dows 95, 98. ME. NT. or 2000. and Win- 
dows-compatible 16-bil sound card. Best 
sound reproduction with headphones or 
high-fidelity audio speakers. 

A variety of teaching aides ha\'e appeared 
on the market over the past .^0 years to as- 
sist students and practitioners in learning to 
recogni/e and describe lung sounds. Initial 
teaching aides consisted of audiocassettes 
that contained a medley of normal and ab- 
nonnal lung sound samples. Such products 
are a bit [iionotonous and lack the ability to 
.stimulate the learner with sinuiltaneous vi- 
sual and auditoiA stmiuli. cittcn lca\ing the 
listener wondering whether the sound was 
inspiratory or expiratory because of the lack 
of \isual cues. Those problems arc now 
solved with the R.A.L.E. Lung Sounds 3.0 

This product is a tutorial program de- 
signed for "physicians, nurses, and allied 
health professionals or anyone listening to 
lung sounds." I found the program appro- 
priate for students as well as practitioners. 
The langtiage of the program is self-con- 
tained and does not require a medical back- 
ground, hut an understanding of pulmonary 
anatomy and physiology is helpful, and a 
World Wide Web link to a review of pul- 
monary anatonn and physiology is pro\ ided 
early in the program. 

The program's design is unique and well 
thought out. The text is on the right side of 
the screen: the left side shows color figures 
and sonograms of sound samples that relate 
to the corresponding discussion. The reader 
.scrolls through the text and clicks im \isual 
cues in the text to trigger the appearance of 
figures and sound samples that coincide w ith 
the text. As a result, the reader can work at 
his or her own pace and repeat sections and 
sound samples as often as needed. The lung 
sound examples are beautifully presented 
with sonograms that ilhistrale the intensity 
and frequency of the example with coloi In 
addition the sonograms have parallel (low 
graphs that allow the listener to note the 
corresponding inspiratory and expiratory 
breathing cvcle. The listener does not have 

to guess which sounds are inspiratory and 
which are expiratory, as when listening lo 
an audio cassette. The sound samples present 
a thin vertical line that displays across the 
screen as the sound is played, which allows 
the listener to match the color sonogram 
display with the parallel tlow graph. 

The program begins with an introduction 
to acoustics. This section is a little technical 
but very helpful to learn how sound is cre- 
ated and perceived. The reader gains a bet- 
ter understanding of sound amplitude, fre- 
quency, and intensity, and this section also 
helps to understand the sonograms later in 
the program. This section also includes brief 
overviews of how the human ear functions 
and use of the stethoscope, and a link is 
provided to a World Wide Web site that 
describes the history of the stethoscope, 
shows pictures of early monaural stetho- 
scopes from the 1800s. and describes how 
Laennec came to produce the first modem- 
day stethoscope. 

The next section describes the basics of 
lung sounds: normal breath sounds, adven- 
titii)us lung sounds, and other sounds. Ex- 
cellent discussions and sound samples of 
tracheal, bronchovesicular. and vesicular 
breath sounds are presented. The program 
describes ht)w normal and abnormal breath 
sounds are created. Adventitious lung 
sounds presented include examples of fine 
and coarse crackles, wheezes, rhonchi. and 
stridor. The discussion covers current un- 
derstanding ofhow adventitious lung sounds 
are produced in the lung when disease is 
present. The other sounds in this section 
include grunting, friction rubs, squeaks, and 
squawks. This section concludes u ith a list 
of current references. 

The next section includes b case studies 
of such disorders as asthma, pneumonia, and 
interstitial pulmonary fibrosis. The cases are 
relatively brief but illustrate how lung aus- 
cultation can be very useful in the diagnosis 
of pulmonary disorders. Cases of adult, pe- 
diatric, and infant chest diseases are included 

The final seclion ol the program presents 
24 quiz lung sounds with which to test your 
ability to recognize iu)rmal and abnormal 
lung sounds, each of which is presented with 
a color sonogram. The user is also asked to 
indicate the timins; of the sound durini; the 

respiratory cycle (eg. early, mid. or late in- 
spiratory). Once the user has settled on an 
answer, he or she clicks on an indicator to 
see the correct answer, which is presented 
by shading the correct response in blue. I 
did not disagree with any of the 24 answers 
pro\ ided by the authors. 

The authors of this program \\ iseh chose 
to use the nomenclature encouraged by the 
International Lung Sounds Association: 
crackles for discontinuous adventitious lung 
sounds, wlieezc for high-pitched, continu- 
ous adventitious lung sounds, and rhonchi 
for low-pitched, continuous adventitious 
lung sounds.' I commend the authors for 
using the recommended nomenclature, as it 
may help standardize the terms used by cli- 
nicians to describe ad\ cntitious lung sounds. 

The onl\ problem I found with this pro- 
gram was the labeling of Figure 18b. The 
"inspiratory" sound of this sample is. in my 
opinion, an expiratory sound and vice versa. 
This error is also repeated in quiz sound 
sample number 8, This error does not de- 
tract from the primary purpose of the sam- 
ple, which IS to teach how rhonchi present, 
but could mislead the novice. 

The program was very easy to load; it 
onl\ look about 3 minutes. I used a com- 
puter with the Windows 98 operating sys- 
tem, a Pentium 1 MMX processor (233 
MHz). 32 megabytes of random-access 
memory, and a Yamaha sound c;ird, 1 rec- 
ommend the use of head phones for good 
sound t|iialit\. 

In summaiN. the R..\.L.L. Lung Sounds 
3.0 program is a complete package designed 
to teach students and practitioners how to 
recognize normal and abnormal lung sounds. 
The authors present each sound sample with 
exciting color sonograms and tlow tracings 
lo illustrate the samples and allow the lis- 
tener to sec which sounds are inspiratory 
and which are expiratoiy . The price of the 
package is very reasonable, especially con- 
sidering the level of expertise and technol- 
ogy that went into producing it. The user of 
this program will gain excellent sound rec- 
ognilion skills and learn the proper use of 
appropriate terminology to describe lung 
sounds. I highly recommend this product to 
educators who desire a better understanding 
of lung sounds for their students, to man- 
agers ot respiratory care dep;irtments who 


Rf;,spir.\t()ry C.-\rf • Shptkmber 2002 Voi, 47 No 9 

Books. Ri ms, Taphs, & Soitwarr 

are looking for ways lo educate their slalT 
on bedside patient assessnienl skills, and to 
clinicians who care for patients with chest 

Robert L Wilkins RRT PhD FAARC 

Depiirlmenl oi Cardiopulinonar> Sciences 

School of Allied Health Professions 

Loma Linda I'niversity 

Lonia Linda. California 


1 . Mikanii R. Murao M. Cugell DW. Chretien 
J. Cole P. Meier-Sydow J. et al. Interna- 
tional Symposium on Lung Sounds. Syn- 
opsis of proceedings. Chest 19X7:92(2): 

Shortness of Breath: A Guide to Better 
Living and Breathing. 6th edition. Andrew 
L Ries MD MPH. Patricia J Bullock RRT. 
Catherine -A Larsen MPH. Trina M Lim- 
berg RRT. Roseann Myers RN. Toni Pfister 
MSc. Dawn E Sassi-Dambron RN. and 
Jamie B Sheldon PT. St Louis: Mosby . 200 1 . 
Soft cover, illustrated. 1.3.^ pages. $9.95. 

The title of this 6th edition of a classic 
pulmonary rehabihtation text appropriately 
designates the book as a "'guide." Dr Ries 
and his pulmonary rehabilitation team have 
organized a valuable guide for both patients 
with chronic lung disease (CLD) and all 
health care providers who care for patients 
with pulmonary disease. The guide will be 
useful to both groups for different reasons. 

Shortness of Breath: A Guide to Bet- 
ter Living and Breathing is a title that 
catches the eve of any person who experi- 
ences shortness of breath. Tliis was the case 
for a chronic obstructive pulmonary disease 
(COPD) patient enrolled in my pulmonary 
rehabilitation program. He purchased the 
text and subsequently shared his review with 
me. His initial comments were that the text 
is an excellent overall picture of how to live 
with lung disease; it should be used as an 
introduction to the field of self-care; and it 
serves as a reminder of what he should be 
doing. He went on to say that pulmonary 
rehabilitation sessions are essential to tlesh 
out the preliminary information gleaned 
from this guide. 

I concur with my patient's observations. 
As a guide for patients u ith pulmonary dis- 
ease, the 6th edition of Shortness of Breath: 
A Guide to Better Living and Breathing 
introduces a great man\ topics but covers 
few in detail. The infomiation presented is 
sound and generally well organized. The 

illustrations are appropriate and the joxial 
characters bring a smile lo the reader and 
convey tlie authors" theme: '". . . our belict 
that persons with breathing problems can 
become active members of the Irealmenl 
learn, accepting (and enjoying) the fact that 
they can and must play a central role in 
their own care." 

For health prolessionals who care lor 
CLD patients this guide is a must-read. Upon 
reading this text, physicians, respiratory 
therapists, nurses, exercise physiologists, 
physical therapists, occupational therapists, 
dieticians, pharmacists, and other profes- 
sionals who care for CLD patients will be 
exposed to the topics that should be included 
in a patient-education program. The topics 
discussed mirror the curriculum of a com- 
prehensive pulmonary rehabilitation pro- 
gram. This guide is written at a level that 
will be understood by most patients, and 
professionals who have difficulty translat- 
ing their medical knowledge into terminol- 
ogy understandable to patients can use this 
text as a template for patient teaching. 
Dr Ries et al share their years of patient 
teaching experience in the 19 chapters and 

The first 3 chapters, "What Are Short- 
ness of Breath and Other Breathing Prob- 
lems All About?" "'The Lungs: How They 
Are Put Together and How They Work," 
and "COPD: What Does That Mean?", out- 
line lung disease in very general terms. In 
the first chapter iny patient reviewer was 
confused reading the explanation in the sec- 
tion, ""What Kinds of Lung Disease Are 
There?"" Chapter 1 concludes with ""The Cen- 
tral Points," which appropriately states that 
this is simply a brief summary and refers 
the patient to his or her physician for clar- 
ification of the diagnosis. Chapter 2 very 
effectively uses illustrations and analogies 
to simplify normal lung function. Included 
in Chapter 3, along with the explanation of 
the pathophysiology of COPD. is a brief 
review of diagnostic testing. Chapters 1, 2. 
and 3 provide patients with baseline knowl- 
edge from which to fomiulate questions 
about their diagnoses, and they provide the 
health care professional with examples of 
how to translate medical jargon into under- 
standable infomiation for patients. 

"Understanding Your Medicines" (Chap- 
ter 4| contains general medication informa- 
tion and describes the classifications of med- 
ications commonly prescribed to pulmonary 
patients. Without the patients knowing 
which classification of medications they are 

taking, since no brand names and few ge- 
neric names are given, this chapter alone is 
ol little benefit to the patient. The inclusion 
ol cromolyn sodium and nctlocromil. with 
no mention of leukotriene inhibitors, dales 
this chapter. I'lic discussion ot oxygen as a 
medication is excellent. As with the preced- 
ing chapters, this chapter raises more ques- 
tions than it may answer for the patient but 
again offers the health care provider excel- 
lent examples for use in patient teaching. 

""Respiratory Therapy: What Oxygen and 
Aerosols Can Do for You" (Chapter 5\ is 
much more comprehensive than the preced- 
ing chapters. This chapter co\ers what pa- 
tients and health care providers should know 
about supplemental oxygen therapy, includ- 
ing options in oxygen delivery systems. Spe- 
cific instructions are included for aerosol 
therapy via metered-dose inhaler and small- 
volume nebulizer. Use of a spacer or ex- 
tender with a metered-dose inhaler is dis- 
cussed, but holding chambers and their 
advantages are not. In the discussion on 
cleaning respiratory equipment, the inclu- 
sion of vinegar as a disinfectant is advo- 
cated despite having fallen out of favor with 
many. The inclusion of recipes for prepar- 
ing sterile water and normal saline is prac- 
tical and much appreciated. 

""The Art of Better Breathing and Cough- 
ing" (Chapter 6) offers instruction in pursed- 
lip breathing, belly breathing, and controlled 
coughing. For the most part these topics are 
discussed effectively, in easily understood 
language. With the major focus of this guide 
being the COPD patient, I was surprised not 
to find in the instructions for pursed-lip 
breathing the specific instruction of avoid- 
ing forced exhalation. Also, rather than in- 
cluding controlled coughing w ith breathing 
techniques, it would have been more logical 
to discuss it in the chapter on bronchial hy- 
giene techniques. 

In the absence of an occupational thera- 
pist, "'Day In, Day Out: Your Daily Activ- 
ities" (Chapter 7) supplies the patient and 
health care provider with information to ap- 
ply breathing strategies and energy conser- 
vation techniques to activities of daily liv- 
ing. Chapter 1 1. '"You Are What You Eat," 
is equally coniprehensi\c, if the services of 
a dietitian are not a\ailablc. Generally, the 
dietary content is broad in scope and uni- 
versally applicable; the text states, ""to main- 
tain good nutrition is to use common sense."" 
Dietary topics of interest to pulmonary pa- 
tients are also addressed, including gas and 

Respirator> Carp • .Sf.ptember 2002 Vol 47 No 9 


Books, Films. Tapf.s, & Soitware 

(.lisiL'iiticm. loss 1)1 nuisclc mass, and Idss of 

"Cleaning Out ^ our lubes: Uioiiehial 
Hygiene" (Chapter 8 ) is eomprehensive, list- 
ing the tollowini; as bronehial hygiene strat- 
egics: eoughing. positive expiratory pres- 
sure, autogenic drainage. Ilutter valve, 
bronchial drainage, chest physiotherapy, and 
exercise. But without the inclusion of more 
specific instniction a patient could not be 
expected to perform these techniques after 
reading this chapter. This is acknowledged 
b\ the authors, who recommend receiving 
instruction prior to therapy initiation. The 
only illustration in the text that baffled me 
was the cough schematic on page .'56. 

The rationale for why a person w ith CLD 
should exercise is succinctly discussed in 
the first 2 paragraphs of "Exercise to Better 
Health" (Chapter 9). The chapter recom- 
mends that the patient should consult with 
his or her physician or other health care 
professionals for guidance in constructing 
an exercise program. For rehabilitation pro- 
grams that do not have the services of an 
exercise physiologist or physical therapist. 
the remainder of the chapter is an excellent 
resource. Endurance, strength, and flexibil- 
ity — the essential components of an exer- 
cise program — are discussed. Illustrations 
similar to those of the stretching exercises 
would be helpful for the Arm-R-Size exer- 

Techniques for relaxation and coping 
with chronic disease are discussed in Chap- 
ters 10 and 14. "Letting Go: Relaxation 
Techniques" (Chapter 10) outlines progres- 
sive relaxation and briefly mentions medi- 
tation, massage, and biofeedback. This 
chapter is another example of being ques- 
tion-provoking rather than instructional. 
Conversely, "The Psychology of Better 
Breathing" (Chapter 14) is the most coni- 
prehensixe. well-written chapter in this 
guide. The effect of CLD on the patient, 
family, and friends is discussed, with the 
bottom line being. "Remeniber: always fo- 
cus on vshal you ctin do. not just what you 

The travel guides and Web pages listed at 
the end of "You Don't Have to Be Grounded: 
Leisure Lun. Recreation, and Travel" (Chap- 
ter 12) are excellent resources for patients. 
The balance of Chapter 12 reviews practical 
considerations to be made by a pulmonary 
patient prior to traveling. It would have been 
more logical to place "Getting It All To- 
gether" (Chapter 16). after discussing lei- 
sure and travel, than in its current location. 

following the discussion on advance direc- 
tives. Chapter 16 assists in preparing a daily 
schedule, with the inclusion of "activities 
you enjoy." 

Avoidance of nritants is discussed in 
"Smoking. Smog, and Other Bad Stuff 
(Chapter LI). The effects of smoking, tem- 
perature, humidity, second-hand smoke, air 
pollution, industrial pollution, allergies, and 
infections are all discussed in 4 pages. This 
guide provides an introduction to these 
topics but not the detail that is traditionally 
presented in a pulmonary rehabilitation 

"When to Call Your Doctor and What to 
Do in an Emergency" (Chapter 15) offers 
very practical information. Included in this 
chapter is the discussion of advance medi- 
cal directives. From the information pro- 
vided it is difficult to differentiate between 
a living will and a durable power of attor- 
ney for health care. The use of the phrase 
"pre-hospital advance directive," rather than 
"do not resuscitate form in your home," 
would be more recognizable. Encouraging 
the investigation of hospice care is very ap- 
propriate and frequently overlooked. 

My patient reviewer thought that Chap- 
ter 17, "You Don't Have to Do It Alone: 
Pulmonary Rehabilitation," should be one 
of the first, if not the first chapter in this 
guide. Attending a pulmonary rehabilitation 
prograin can pull together all of the infor- 
mation presented in this guide by assisting 
patients in recognizing which portions of 
the guide are appropriate for their care. The 
inclusion of patient populations other than 
COPD in pulmonary rehabilitation programs 
is essentia! know ledge lor patients and health 
care providers and is discussed in this 

A new chapter in this sixth edition is 
"Resources: Where to Go for Information" 
(Chapter 18). Readers are encouraged to fur- 
ther enhance their knowledge by accessing 
support groups and resources on the Inter- 
net. The World Witle Web sites listed are 
current and known for accurate information. 

The last chapter, "A Look to the Future" 
(Chapter 19), reviews curtent and future re- 
search questions. The 6 pages following 
Chapter 19 are a glossary, and my patient 
reviewer thought that the glossary section 
alone made this book worth its reasonable 

Continuing to stand as a classic, the 6th 
edition o\ Shortness of Brenlh: .\ Guide 
to Better l.i>iii)i and Breathing is an es- 
sential guide for palicnis w i(h CLD and their 

health care providers, and it should be pur- 
chased, read, and put into practice. 

Bonnie F Fahy RN MN 

Pulmonar) Rehabilitation 

St JosL|ih's Hospital and Medical Center 

Phoenix, Arizona 

Radiologic Diagnosis of Diseases of the 
Chest. Nestor L Miiller MD PhD, Rich;ird 
S Eraser MD, Neil C Colman MD, and PD 
Pare MD. Philadelphia: WB Saunders. 2001. 
Hard cover, illustrated. 790 pages. $135, 

This 790-page book is organized into 23 
chapters and an index. This is 2A0O pages 
less than the 4-volume. 4th edition of the 
classic Dicii^iiosis of Diseases of the Chest 
by the same authors, from which this book 
is derived. Included, however, is all the rel- 
evant radiologic information from the par- 
ent book, but with only the essential etiol- 
ogy, pathology, and clinical elements. New 
to this work is an information update from 
the 1999 copyright of the larger work, with 
many new illustrations and tables. 

The chapters follow a presentation and 
logic similar to the larger work, covering: 
the normal chest: investigative methods in 
chest disease: radiologic signs of chest dis- 
ease; de\elopmental lung diseases: pulmo- 
nary infection: pulmonary neoplasms; lym- 
phoproliferative disorders and leukemia; 
immunologic lung disease: chronic intersti- 
tial lung disease; pulmonary manifestations 
of human immunodeficiency virus infection: 
transplantation: embolic lung disease: pul- 
monary hypertension; pulmonary edema; 
diseases of the airway s; pulmonary disease 
caused by inhalation or aspiration of partic- 
ulates, solids, or liquids; pulmonary disease 
caused by toxins, drugs, and irradiation; trau- 
matic chest disease; complications of ther- 
apeutic and monitoring devices; metabolic 
pulmonary disease: pleural disease; medi- 
astinal disease; and diseases of the dia- 
phragm and chest wall. Missing is a chapter 
on pulmonary disease associated with a nor- 
mal chest radiograph. Though most of these 
chapters are pared-dov\n \ersions from the 
larger work, some are expanded sections 
from the larger book's subheadings, such as 
the chapters on pulmonaiy manifestations 
of human immunodeficiency vims infec- 
tions and transplantation. 

All the chapters are organized in the same 
format, which makes for consistent read- 
abilits . The hook includes extensive discus- 
sion of most imaging modalities, including 
spiral and high-resolution computed tomog- 


Respiratory Care • September 2002 Voi 47 No 9 

Books. Fii ms, TaitiS. & Softwarh 

raphy, cunvcntidnal catheter angiography, 
and nuclear mcJicine scans. There is a pau- 
city ot inlonnatiiin on magnetic resonance 
imaging and ultrasonography, but this is ap- 
propriate and as expected, as there is little 
clinical use for those methods in chest im- 
aging. Additionally, there are some well- 
placed pathology illustrations, both gross 
and microscopic, and the images are beau- 
tifully presented and reproduced. In addi- 
tion to the authors" own material, appropri- 
ate images were borrowed from numerous 
sources to more completely illustrate the dis- 
ease processes. A minor weakness of this 
te.xt is the lack of discussion of modem com- 
puted tomography angiography. 

One of the book's best features is the 
collaborative emphasis on the disease itself. 
written by world-class pulmonologists. pa- 
thologists, and radiologists, for those who 
have special interest in chest diseases. 

Though the larger work from w hich this 
book is deri\ ed is a peerless reference source 
for a complete understanding of all aspects 
of chest diseases, this smaller \ersion fo- 
cusing on the radiologic diagnosis of chest 
diseases accurately reflects iriost of the cur- 
rent radiologic advances in the study of chest 
disease. When compared with other such 
books, this one packs a big radiologic punch 
for the comparatively inexpensive price of 

Eric J Stem MD 

Departments of Radiology and Medicine 

Harborview Medical Center 

University of Washington 

Seattle, Washington 

CT Angiography of the Chest. Marline 
Remy-Jardin MD PhD. Jacques Remy MD. 
John R Mayo MD. and Nestor L. Muller 
MD PhD. Philadelphia; Lippincott Williams 
& Wilkins. 2(X)1. Hard cover, illustrated. 
148 pages, $110. 

As stated in the author's preface, this book 
is "written by experts who are internation- 
ally known for their pioneering work in spi- 
ral computed tomography." 1 could not agree 
more. This book is a state-of-the-art guide 
to the techniques and clinical applications 
of computed tomography (CT) angiography 
(imaging of vessels) of the chest. It was the 
advent of multi-row-detector CT scanners 
that enabled CT to image vessels, and not 
just in cross-section. This new CT technol- 
ogy allows for \'ery rapid volumetric image 
acquisition. With one of these new scanners 
a complete chest CT scan can be obtained 

within one 10-second breath-hold, and at 
remarkable resolution. Commercially avail- 
able software packages now allow the cross- 
sectional image data to be manipulated into 
incredibly revealing sagittal and coronal 
planes, as well as 3-dimensional images, and 
the authors make appropriate use of that 
software, not just in "gee-whi/'" imaging, 
bul in showing the practical use of these 

Topics covered include technical consid- 
erations of chest CT angiography, anatomy 
and normal \'ariants thereof, and normal and 
pathologic conditiims of both the lung and 
mediastinum. 1 found the anatomy and nor- 
mal variants chapter to be very interesting, 
with information not typically available in 
other imaging textbooks. Specific chapters 
include succinct discussions of the "hot top- 
ics" of acute pulmonary embolism and aor- 
tic trauma as well as the rarer, though no 
less interesting or well written, topics of 
thoracic outlet syndromes and vascular 
anomalies of the lung. The book is orga- 
nized into 10 chapters, with a total of 148 
pages. The chapters ;ire about 10-20 pages, 
making for generally quick reading. 

The authors make practical use of tables, 
generally listing disease etiologies and suc- 
cinct clinical and radiologic features of dis- 
eases and abnormalities. There is unifomi 
image size in 2 columns. The image an- 
chors are well placed in the text so there is 
little "hunting about" for the corresponding 
image. The image quality is generally ex- 
cellent throughout the book. 

There are no similar texts at the time of 
this writing. Though this is a cutting-edge 
textbook, this field is in relatively rapid flux 
because of rapid changes in the technical 
aspects of CT angiography. This field is 
still in its infancy, without as yet wide dis- 
semination of the CT scanners necessary to 
take advantage of this technology, although 
each day more centers are acquiring the nec- 
essary multi-row-detector CT scanners. This 
book offers a fast, easy-to-read, authorita- 
tive review of this new application for CT 
scanning. It's not just axial images any 
longer. I expect that this book will be up- 
dated relatively quickly as the clinical use 
of CT angiography expands to keep up with 
the improvements in technology. 

This book will be of interest to all gen- 
eral radiologists, subspecialists in chest ra- 
diology, and even to pulmonologists or other 
health care providers with strong interests 

in imaging. This book is the dc facto stan- 
&M\\ in this rapidly progressing field. 

Kric .1 Stern MI) 

Depailmenls of Radiology and Medicine 

Harborview Medical Center 

University of Washington 

Seattle. Washington 

Imaging of the Chest: A Teaching File. 

Patricia J Mergo MD. Editor. Philadelphia: 
Lippincott Williams & Wilkins. 2002. Hard 
cover, illustrated. 271 pages. $95. 

As a "teaching file" rather than a stan- 
dard text, this book is useful for one who 
already has basic knowledge of chest imag- 
ing and wants to test his or her knowledge. 
Reviewing this teaching file is similar to a 
radiologist's routine work of reviewing ra- 
diographs, describing the findings in rela- 
tion to the patient's clinical history, and 
yielding a diagnosis or diagnoses when the 
findings are specific enough. The format is 
also similar to what radiology residents face 
in their teaching conferences. The book has 
discussions about the natural history of and 
radiologic findings associated with the dis- 
eases, and some discuss pathology cor- 
relations and treatment regimens as well. 
The author does not give long lists of pos- 
sible diagnoses but. instead, concise differ- 
ential diagnoses well-correlated with the 
clinical histories. 

The book's content is grouped by pattern 
of findings (pattern of lobar collapse, cavi- 
tary lung lesions, lung neoplasm and other 
masses, hyperlucent lung and airways, and 
abnonnal air collections) and by the loca- 
tions of the abnonnalities (airspace disease, 
interstitial disease, mediastinal disease, and 
pleural disease). Of the hook's 9 chapters, 
the most impressive is Chapter 7. "Medias- 
tinal Disease," because of the "key imaging 
findings" boxes that follow most of the cases 
presented and help lo reinforce the findings. 
Certain of the other chapters hav e too many 
examples of one disease and a lack of other 
interesting cases from the same group ot 
diseases. Forexample. the first chapter. "Pat- 
terns of Lobar Collapse." shows the pat- 
terns (one case of each) of right upper lobe 
collapse, right middle lobe collapse, and lin- 
gular lobe collapse, and 2 cases of left lower 
lobe collapse, but there is no example of 
right lower lobe, left upper lobe, or com- 
bined lobar collapse, which would be of 
interest. In the second chapter. "Airspace 
Disease." nearly half of the cases are about 
pneumonia from various organisms, most 

Respiratory Care • September 2002 Vol 47 No 9 


Books. Films. Tapes. & Software 

ot which have nonspecific chest radio- 
graphic findings. 

For the most part the content is appro- 
priate, but there are, in my opinion, a few 
eiTors of diagnosis presented. For example, 
case 62 should have had a diagnosis of pul- 
monaiy laceration (rather than pneumato- 
cele) and case 98 should have had a diag- 
nosis of paraseptal emphysema with 
vanishing lung syndrome (not centrilobular 
bullous emphysema). 

Most of the figures are well-correlated 
w ith their legends, but the legends for case 
figures 1, 7. 29, and 55 describe findings 
not shown in the images. 

This book has an '"outstanding" magenta- 
colored hard cover, which is conveniently 
easy to recognize. The publisher used good 
quality paper, the typeset is easy to read, 
and the book is not too krrge or heavy to 
easily handle. However, the binding of my 
copy became loose during the month in 
which I first had the book. Also, not all the 
book's images are of good quality; many 
have poor resolution and are difficult to in- 
terpret, and I thought that all the lateral chest 
radiographs should have been arranged in 
the same orientation, for consistency. A 
more important shortcoming is that, in about 
6 instances, scout images, which are not 
standard images for interpretation, are used 
as examples of posteroanterior or antero- 
posterior chest radiographs. 

The index is well organized but does not 
include entries for some temis in the book, 
especially radiologic signs such as Gold- 
en's S sign, Hampton's hump, crazy pav- 
ing, tree-in-bud. et cetera. 

The 150 cases in this teaching file should 
be useful to residents and staff in helping 
them more confidently identify common 
chest diseases. 

Nisa Thoongsuwan MD 


Thoracic Radiology 

Harborview Medical Center 

University of Washington 

Seattle, Washington 

Medical .Applications of Computer Mod- 
cllin};: The Respiratory System. TB Mar- 
tonen. Editor. Southampton UK: WIT Press. 
2(M)I. Hard cover, illustrated, 345 pages, 

This book is the second of 2 vt)lumes 
that deal with computer modeling and fluid 
dynamics in biological systems. The pur- 
pose is to integrate computer technology and 

mathematical modeling into the biomedical 
realm. Early chapters locus on general con- 
cepts of the modeling employed, whereas 
later chapters provide detail on the applica- 
tion of computational fluid dynamics. 

Chapters in the book examine the me- 
chanics of air flow in the respiratoiy system 
at all levels, including the nasopharynx and 
large and intemiediate size airways. The fi- 
nal chapters deal with imaging techniques 
to assess aerosol deposition and features of 
inhaled drtig delivery. Twelve chapters take 
the reader progressively from the outside 
environment to the alveoli. Chapters cover 
the morphology of the respiratory system, 
including extralhoracic, lai^ngeal, individ- 
ual tracheobronchial airways, and airway bi- 
furcations. Later chapters focus on devices 
used to produce aerosolized drugs and hu- 
man subject inhalation exposure protocols 
and experimental techniques to determine 
lung deposition patterns in human subjects, 
using imaging techniques. The book is in- 
tended to provide reference material for in- 
vestigators directly involved in this type of 
research and to provide educational mate- 
rial for the classroom. 

The book is strongly bound and has an 
attractive cover. The print is of good quality 
and easy to read. Some of the chapters are 
concise and well organized. The first 2 chap- 
ters are introductory. Several chapters are 
quite long but are filled with useful data and 
insight about computer predictions. 

Though this book is comprehensive and 
well written, it requires a certain understand- 
ing of engineering principles and equations. 
The book may not be particularly helpful 
for respiratory therapists in clinical practice. 
However, the book should be mandatory 
reading for researchers studying flow dy- 
namics in the respiratory system. 

Michael P HIastala PhD 

Department of Physiology and Biophysics 

Division of Pulmonaiy 

and Critical Care Medicine 

Department of Medicine 

University of Washington 

Seattle, Washington 

Statistical Methods for Anaesthesia and 
Intensive Care. Paul S Myles MB BS MPH 

MD and Tony Gin MB ChB MD DipHSM. 
Oxford, United Kingdom: Butterworth Hei- 
nemann. 2000. Soft cover, illustrated. 152 
pages, $42.50. 

Statistical Methods for Anaesthesia 
and Intensive Care is written as a brief 

overview of common statistical methods 
used in the anesthesia and intensive care 
literature. This book covers descriptive sta- 
tistics, inferential statistics, regression, cor- 
relation, predicting outcomes, surv ival anal- 
ysis, basics of clinical trials, and common 
statistical errors. The authors state that the 
book "'. . . is written by anaesthetists for an- 
aesthetists and clinicians. ..." The aim of 
the book ". . . is to explain a variety of sta- 
tistical principles in such a way that ad- 
vances the application and development of 
our knowledge base, and promotes the sci- 
entific foundations of our unique specialty: 
anaesthesia and intensive care." I found that 
this small book meets that aim. except for 
some minor errors that 1 will discuss below. 
This book will be useful to health care pro- 
viders in anesthesia and intensive care from 
all specialties. Although most of the exam- 
ples used are from the anesthesia literature, 
they are presented in such a way that any- 
one involved in evaluating statistical meth- 
ods in the medical literature will understand 
the principles. The writing style is clear and 
easy to follow, without overuse of statistical 
terminology. Each chapter starts with a chap- 
ter outline and a list of the chapter's key 
points. The presentation of the most com- 
monly used statistical tests includes the as- 
sumptions of each test and when the test is 
appropriate and inappropriate. 

Chapter 1 discusses the 4 types of data 
involved in statistical analysis: nominal, or- 
dinal, interval, and ratio. This chapter also 
discusses the differences between discrete 
numerical data and continuous numerical 
data. The basics of descriptive statistical 
techniques are discussed in Chapter 2. The 
data presented in Figure 2.1 should have 
been presented as a histogram rather than a 
bar diagram, since these are continuous data. 
The binomial distribution calculation in ex- 
ample 2.3 has several typographical errors. 
The equation shown is: 

9.8 , 
P{2) = ^.2-(l -0.2)' 

= 36. (0.4). (0.21) = 0.30 (1) 

The coiTCCt equation is: 

P(2) = ;^-^.2=(l -0.2)' =36 

X (0.4) X (0.21) = 0.30 (2) 


Respiratory Care • September 2002 Vol 47 No 9 

Books, Films. Tai'i-.s. & Softwakh 

The format of the equation ilkistrating 
the Poisson distribution in Example 2.4 is 
also incorrect. The equation shown is: 

/'(l) = f "-"(1 +0.33) = 0.24 (3) 

The correct equation is: 

Pil) = e"""( —^1 = 0.24 (41 

This chapter only shows one graphical 
method of summarizing data; the box and 
whisker plot. This chapter could be im- 
proved by including other graphical meth- 
ods of summarizing data that are found in 
the medical literature. 

Chapter 3 does an excellent job of clearly 
summarizing the basics of inferential statis- 
tical analysis, including easy-to-understand 
definitions of Type 1 and Type II statistical 
errors. This chapter also introduces the cal- 
culation and importance of confidence in- 
tervals, power analysis, and sample size cal- 
culations. The distinction between 
parametric and nonparametric tests is sum- 
marized in Chapter 3. 

Common medical research designs, 
blinding, and randomization techniques are 
discussed in Chapter 4. 

Very basic, easy-to-read, and mostly 
complete discussions of the common para- 
metric and nonparametric analysis tech- 
niques for comparing groups appear in Chap- 
ters 5 and 6. 

Chapter 7 presents the basics of regres- 
sion, correlation, and agreement analyses, 
including the assumptions, advantages, and 
disadvantages of each. 

Bayes's theorem and prediclixe value cal- 
culations of diagnostic tests iire presented 
brictly in Chapter 8. This chapter could be 
improved by expanding the niniiber of ex- 
amples to better ilUisirale the specificity and 
sensitivity of common diagnostic tests and 
how these can be used in predicting out- 

Chapter 9 presents a very brief introduc- 
tion to survival analysis, which is adequate 
for a basic understanding of survival anal- 
ysis when reading the literature. This chap- 
ter should be expanded to discuss the math- 
ematical techniques needed to develop and 
implement a sur\ival analysis study. 

Chapter 10 briefly discusses large clini- 
cal trials, meta-analysis, and evidence-based 
medicine. This chapter would be greatly im- 
proved by adding more discussion and ex- 
amples of the use of clinical practice guide- 
lines in evidence-based medical practice, 
especially in the intensive care setting. There 
is one eiTor in this chapter that needs to be 
corrected. In the discussion of the odds ratio 
the authors state. "If the 95% confidence 
interval of the odds ratio exceeds the value 
of 1 .0. then it is not statistically significant 
at p < 0.05. ..." The w ord "exceeds" should 
be replaced with "includes" because a value 
of 1 .0 for the odds ratio indicates no effect; 
therefore, if the value of 1.0 is included in 
the confidence inter\al, we can conclude 
that there is no treatment effect. 

The most common statistical errors in 
anesthesia and intensive care are discussed 
inChapter 1 1. Each error is discussed briefly, 
with comments on how to prevent the errors. 

Chapter 12 presents the basic steps in 
designing a clinical trial and includes brief 
discussions of the drug study regulations in 
Australia, the United Kingdom, and the 
United States. 

The final chapter presents several algo- 
rithms designed to assist in selecting the 
appropriate inferential statistical test. These 
algorithms will probably serve the begin- 
ning researcher in 90% of proposed studies. 
More complicated studies should include a 
statistician early in the research design 
stages. There were several topics that were 
discussed twice in different chapters, using 
almost the exact same wording, but this rep- 
etition was not distracting or confusing, be- 
cause the first discussion was a brief intro- 
duction with definitions and the second 
presentation was a more detailed discussion 
that started with a repeat of the material 
already presented. 

In conclusion, I found this book easy to 
read and understand. Although most of the 
examples are anesthesia-related, this book 
will be useful to physicians, nurses, and re- 
spiratory therapists who wish to better un- 
derstand the medical research literature. 

Wesley M Granger PhD RRT 

Respiratory Therapy Program 

Department of Critical Care 

University of Alabama at Birmingham 

Birmingham. Alabama 

Respir.^tory Care • September 2002 Voi 47 No 9 


2002 Open Forum 

at the 

International ^Inspiratory (Congress 

The Annual Convention & Exhibition of the 

American Association for Respiratory Care 

October 5-8, 2002 • Tampa Bay, Florida U.S.A. 


Lhe Open Forum at the International Respiratory Congress is a unique opportunity for attendees to experience the results 
ot scientific studies performed by their colleagues. Abstracts and posters of their work are presented in a symposium format 
that encourages discussion and interactions among investigators and observers. Indeed, some attendees refer to the OPEN 
Forum as the most significant event at the Congress. 

The Respiratory Care Journal is proud to present this year's 1 5 OPEN FORUM SYMPOSIA. Once again, respiratory care 
professionals have stepped forward and anah-zed the things thev do with critical eyes. 

We encourage you to attend and to participate in the exchange when the abstracts and posters are presented. If you have never 
experienced an OPKN FORUM SYMPOSIUM, we guarantee you a unique educational experience. 


SdturcLiy, Oct 5. 2002, 12:30 pm - 2:25 pm 
(Rooms 18-19) 


Saturday. Oct 5. 2002, 12:30 pm - 2:25 pm 
(Rooms 20-21) 


Saturday, Oct 5, 2002, 3:00pm - 4:55 pw 
(Rooms 18-19) 


Saturday Oct 5, 2002. 3:00pm - 4:5^ pm 
(Rooms 20-21) 


Sunday Oct 6, 2002. 12:30pm - 2:25 pm 
(Rooms 18-19) 


Sunday Oct 6. 2002. 12:30pm - 2:25pm 
(Rooms 20-21) 


Sunday Oct 6. 2002, 3:00 pm - ^:55 pm 
(Rooms 18-19) 


Sunday Oct 6, 2002. 3:00pm - 4:55 pm 
(Rooms 20-21) 


Monday Oct 7. 2002. 9:30 am - 11:25 am 
(Rooms 18-19) 


Monday Oct 7, 2002, 9:30 am - 1 1:25 am 
(Rooms 20-21) 


Monday Oct 7 2002. 2:00 pm - 3:55 pm 
(Rooms 18-19) 


Monday Oct 7. 2002. 2:00 pm - 3:55 pm 
(Rooms 20-21) 


Tuesday Oct 8. 2002, 9:30 am - 1 1:25 am 
(Rooms 18-19) 


Tuesd,iy Oct 8, 2002, 9:30 am - 1 1:25 am 
(Rooms 20-21) 


luesday Oct 8. 2002. 1:30 pm - 3:25 pm 
(Rooms 20-21) 

See pages 1094-1097 for Authors Index 



g .proti 




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the management of patients with ARDS. 

Only the 3100B enables the extended use of 
continuous distending pressures to recruit and 
normalize lung volumes while removing CO2 with 
lung protective volumes that are close to 
physiologic dead space. 

By providing a ventilator strategy that delivers the 
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one step further in lung protection. 



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Pressure critical care division 

Saturday. Octobi^r 5, 12:30-2:25 pm (Rooms 18-19) 

Corrclution Between Serum Albumin Levels and Ventilator Length of Stay 
(VLOS) in u Group of Mechanically Nentilaletl Pediatric Patients. 

Ruben D Kcsirv i H^. MP. RRT. IXpnrlnu'nl »>| ( .lutu'piilnion.ii'N Care Sciences, Geor- 
gia Stale L'ni\crMl\. Atlaiila. (JA. 

BACKGROUND: H> poalbumineniia is a common finding in crilically ill patients. It 
has been \\ ell documented that In fK>albuminemic patients have a higher morbidity and 
mortality rate when compared u itii patients \\ iih a normal seaini albumin. Howe\cr. 
albumin replacement to correct hypoalbummemia in cnticail\ ill patients in the ho[>c 
of impro\ in^ their outcome has remained contro\ ersial. Since extended Ventilator 
Length of Sla\ { VLOS I has been assi>ciated with higher morbidity and mortality, cor- 
relation between the scnim albumin levels with the time acutely ill pediatric palicnts 
remain intubated in the intensive care unit can ser\e as a prognostic marker. No study 
has correlated the presence o\ hs poalbuminemia w ith the VLOS in mechanically ven- 
tilated pediatric patients. OBJECTIN'R: To correlate semm albumin levels and venti- 
lator length of stay in a group of mechanically ventilated pediatric patients. 
SETTING: A tertian' pediatric ICC. SUBJECTS: Patients admitted to the PICU 
between March of I ^97 to June of 1 998 w ho underwent mechanical ventilation. 
METHODS: One hundred mechanically ventilated pediatric patients were reviewed 
as part of ongoing research examining mechanical ventilation weaning in pediatnc 
patients. Semm albumin le\el was measured on 64 patients upon admission. H\poaI- 
buminemia was classified as mild (2.5 - 3.5 g/dL) and severe (< 2.5 g/dLl. 
OUTCOME MEASURES: Length of mechanical ventilation. RESULTS: A total of 
64 charts of mechanically \entilated pediatric patients were reviewed. Independent t- 
tests for equality ol means were used to compare VLOS and albumin levels. The mean 
(+ SD) serum albumin level for all patients was 3,0 + 0.7 g/dL. The patients with a 
semm;ilbumin level of <2. 5 g/dL had a meiin VLOS of 4.28 ±5.01 days compared to 
patients with semm albumin levels between 2.5 and 3.5 g/dL (2,89+ 3.6 days), and 
patients with serum albumin levels >3,5 g/dL (2.39 + 2.84 days). CONCLUSIONS: 
These data suggests that the presence of hypoalbuminemia upon initiation of mechani- 
cal ventilation in pediatric patients 
murmngnj is correlated w ith a longer \ entila- 
tor length of stay 
{r^-.19 p=0.14). However, a 
larger sample of patients may be 
necessary to show a significant 
difference between the three 
groups analyzed. 



Michael Tracy RRT . Timothy .MyerN BS. RRT. Robert Chatbum RRT. FAARC 
Rainbow Babies and Children's Hospital. Cleveland Ohio 

BACK(;R0UND: Previous work at tiur institution (Respir Can? 2001 ;46( 10): 1 138| 
compaird the measured accurac> of Bird and Nosametrix flow/volume transducers to 
detennine initial accurac> iuid accuracy after ethylene oxide (ETO) sterilizatioas. The 
purpose of this study w as to measure the initial accuracy of the Meteor™ probes, and to 
detemiine if they would maintain accuracy after ETO sterilizations. 

METHODS: Probes studied previously had their manufacturer's accuracy range fnim 
yi to 15*^^. Wearhilrarily set aclinically acceptable errorrange of ±10'7f foruniform 
consistency. The same ±109f was applied to this bench test for consistency in this retro- 
spective comparison. New Meteor pediatric/adult How transducers were evaluated for 
accuracy of tidal volume (Vt) delivery using calibrated syringes. As in our previous 
work, probes were tested at Vt of 2(X». 4(K). 7tX) and 100a;c. Five different prtibes were 
tested new out of the package, and each sensor was independently evaluated five times at 
each calibrated Vt. Data were then analyzed as a f)ercentage error for KMh new 
condition and after each of fi\e resterilizations. Error was calculated a.s the difference 
(measured value -ime value) and expressed as a percentage of the true value. Mean and 
stand;\rd de\ iaiion was calculated for errors across all volumes for each condition (new 
and resienliTalionsi. Error intenals were calculated as mean error ±2.3 1 x SD (Respir 
Care 1996;41:1092-1099) and interpreted as the expected error for 959( of future mea- 
surements at the 99f^ confidence level. 

RESLfLTS: Each number in the table below summarizes 100 volume measurcmenls. 
Data below are lower (L) and upper iC) \alues of the error internals. Bird and 
Nov ametnx data obtained from our prev ions work are included for comparison. 

Slerilizations 1 



























































CONCLUSION: In this bench test, the results indicate that Meteor probe error was 
w itliin the range of \ alues specified by other manufacturers (Bird and Nov ametnx). 
However: they exceeded our standard of acceptible error (± lO*^). while the Bind and 
Novamelrix probes did not. OF-02-042 

Malloy . BS RRT, B. Glynn. BS RRT, A. Kunig. MD, Depatments of Pulmonarv 
Care and Neonatology. Thomas Jefferson University Hospital. Philadelphia. Pa. 

OBJECTIVE: To detennine if Oxygen (02) requirement changes with inhaled 
Nitric Oxide (iNO) in babies with severe chronic lung disease (CLD) of 
prematunty. B.ACKROUND: Babies with severe CLD of prematurity who are 
dependent on the ventilator often require significantly high inspired 02 concentra- 
tion as the disease progresses. Lung injur\ and associated pulmonary hypertension 
reported m these babies is thought to be due in part, to continuous oxidant damage 
which is related to the amount of inspired 02. Since iNO is known to selectively 
decrease pulmonan. vascular resistance and potentially improve ventilation perfu- 
sion, we theorize that low dose iNO w ill reduce 02 requirement in premature babies 
with CLD of prematurity. METHOD: 6 premature babies with initial diagnosis of 
respiratory distress syndrome were studied using the VIP Gold Ventilator to 
optimize ventilation and oxygenation. Inclusion cnieria include > 2 wks old and 02 
requirement of >0.60. iNO was started at lOppm and weaned to 5 ppm and then to 
I ppm for 02 saturations >92r'c before discontinuation. FR)2 was weaned by 2-4';f 
and 02 saturations were maintained between SS and 92*^^ . All MeiHb levels were 
<2 during the study. 

Duration Gest. Age: Day of 














life on NO: (pre) (post 1 hr) (5 days on NO) OFT NO 
































RESULTS: The patients studied were started on iNO at a mean age of 41. S days of 
life. Average gestational age was 27.3 weeks. E102 requirement decreased by an 
a\ erage of I 2-3'y after I hour on iNO and by an average 27. 1 9i after 5 days on 
iNO. PI02 requirement decreased by an average o\' 21.^'"( after iNO was discontin- 
ued. CONCLUSION: These data suggest thai 02 dependent chronically ventilated 
premature babies may benefit from low dose iNO by requiring less inspired oxygen 
concentration. This may potentially reduce lung injury and associated morbidity 
and mortality. Further studies need to be done to determine the efficacy, possible 
complications and for how long low dose iNO can be used for these babies. 


Transport of Criticallv lit Newborns and Children utiliring High Frequeno \ (.-ntilatinn iH¥\ \ 
and Nitric Oxide: A report on the experience at Children's Hospital of Orange Counts. C.\. 

D.VillaredRR.T. J. Cappon. M.D,. J. Clean, M.D 

Introduction: The Children's Hospital of Orange Count\ (CHOCi Transport Teain fa-quenllv uuns- 
ptins ncv^ boms and children with respirator) and /or cardiac failure for HFOV, inhaled Nitnc Oxide 
I NO), and/or ECMO. Increasingly in our referral centers, these children are receiving advanced ihera- 
pics such as HFOV and NO at the time of ret'erraj. We iniegraled the Volunictnc DiltUMve Respiralor 
I VDR I Ventilator iPereussionaire . Corp. S;indpoini. Idaho) series to our neonatal and pediatnc trans- 
porters. Reliable NO deliv er>' using the Aeronox Nitnc Oxide Delivery System (Tofield. Alberta. 
Canada) with the VDR -3C. was established on a bench study. 

Method: We i-eviewedour transport data fnini January of IWQ through December 2001. Our objecUve 
was to. I ) monitor slaff compliance of utili/ing the VDR; 2 (compare the mode ol ventilation beiween 
ihc referring hospital and dunng transptirt, ^icompan: the pre- and post- u~ansp«)rt blocKlg;Lv;-sand Oxv- 
gcn Index (01); and 4i report the etTectivc delivery of NO and HFV under clinical transport conditions. 
Results: During the earlv stages, the compliance for the utilization of the \T)R-3C w as suboptmial To 
impane compliance, wc developed a "train the trainer" prognun and in turn, implemented a prvccpinr 
procedure tor ihosc Respiralorv Care Practilioncrs (RCPl staff as.signed lo transport Suhsequcnih. 
VDR-.^C protocol compliance objectively improved. The venulator mode at the a-femng facililv nuiged 
from hand-venulation. conventional mechanical ventilation iCMV) to HFV, Of the 46 paticnLs, 5 
patients were transported via CM V, 4 were* hand-vemilaied. 1 7 i^^ived HFV and NO. and 20 HF\' 
alone Table I shows the comparison of HFV seltmgs between the refemng facility and immediately 
posl-tr.insport for the 2 1 palienls who received HPv' in both sellings. Table 2 indicates the pre"- and post- 
bltHxl gases and Ol in those patients vvilh completed transport data. 


Refcmng Facihty Venulator Setting: 




Transport Ventilator Setung 





■one palicnl convened o\ er lo CMV, 5 patien 

wen: muisponed on 


T.ihlc 2 

Refemne F.icililv Bkxxi Ga.■.e^ 


p..d Bl.«\) C.,isi-s 1 





















'Ol based on 16 patients. I pauenl has no MAP data pnor to iran-sport. 
(.'ondiLsions; We rc|Xirt ihe succevsful transport of critically ill newborns and children ulili/ing our 
HFV transport s\ stem We found thai succcs.sful initiation of HFV and NO transport pmgram involves 
cviensive training of staff members to the concept of VDR technology and NO therapy. Furthermore, 
wc deiuonslraled significani imprnvenieni in palienl oxygenation and ventilation. 
Sivcial thanks to the CHOC Emergency Traasport Teani for their contnbution in making this 
abstract pos-sible 



Respir,\tory Carf • September 2002 Vol 47 No 9 

Saturday, OcTOBhK 5, 12:30-2:23 pm (Rooms IS-19) 

Bench It-M (if ihf [)r.ij;tr Kah>lo^SIMHI))liis Ni<inulal Niiitiblor «ith IKIiux 
MiMurvs, \lcliv»u K. Bro wn kK'l . Shuqj Miir> hirch llospiial tVir \\ nnivn. Sun 
Dif^o, Culil'omia. 

Backtiruund: Hciiuni-n\ygcn(hclin\) yas iiiiMurvsarvof a lower densiiy than air/oxyjicn 
[iiiMuivs. Inhataiion ol i;;l>. w ith a low -tlctisiiy such as hcho\ can a'ducc ai^^v;ly rvsisiancc. 
This enables inipr\)\cd vcniilaiion iuiil ihc piMenlial lo inca-asc cxpiraiory flow and lo 
decrease lun^: hypennflation and auio-PRRP Then* aa* se\eral suidies documenting the 
beneficial eflects for neonatal patients w ith heliov therapy. 1 sotighi to determine if the 
Draper Bahylog S()()(>plus ventilator could deliver heliox \ia the 5l)-psi airconnectinntti 
the ventilator. Also, the teasibilitv oJ leaving the flow sensor in line to p*)tenliall> enable 
patient tng^ering and synchmnv . and the accuracy ol the o\yi;en blender iuid analy/er in 
the presence of heliox. hi addition, what technical difficulties might be encountered, due to 
the degree of iniiccuracy in \ olumes measuanl by the hot w im anemometer flow sensor' 
Methods. An S(V2l*-helio\ mixture was connected via the 50-psi air inlet of the ventilator. 
The SIMV and .-VC mwics were utilized, prevsures 2(1/5. r .^0. 0.4 inspiratory time w ith 
heliox mixtures in 5- lO^r increments fuim IOAM)io 79/21, FiO; was measured e\temall\ 
with a Maxtet MaxO^electnK'hcmical analy/er (Salt Uike City. Utaht. Volumes were 
measured with the Novametrix Co^smo plus Respirator. Mechanics Monitor (Wallingford 
CT). which contains sol'iw;ire programmed lor compensation ol heliox mixtures. The hot 
wire flow sensor was left in Une for all concentrations except 75/25 ajid 79/21. when the 
high minute alann maximal threshold was breached ( 1 5 L/min I and could not be disabled. 
Results. The Drager Baby log SOOOplus cycled consistently with all heliox n^xlures. Once 
heliox concentrations reached 50/50 the v enlilator flow sensor w as no longer able to 
display any tidal v olume on the lest sellings and the apnea alarm had to be disabled. When 
heliox concentrations reached 75/25 the flow sensor hud lo be removed enabhng IMV ven- 
tilation only. The ventilator oxygen analyzer was within 1 9t of the external analyzer, but 
the blender was as much as 9*7 off causing audio and visual alarms, due lo internal alami 
limits of + 4^ f of the internal oxygen anaiy zer. The ventilator flow sensor tidal v olumes 
wereeitheremmeousor unable to read an\ volume^ all concentrations of heliox. Con- 
clusion. The Drager Baby log 8(XK)plusgas mixing system has a zero internal bleed How, 
enabling heliox mixtun;s to be introduced Ihniugh the 50 psi air inlet, w iihoul wasting gas 
and allowing consistent cycling of ihe ventilator. The ventilator oxygen analyzer is accu- 
rate, but has to be disabled to overcome the constant alarm condition caused by the 
disagreement between blender selling and FiO: delivered. The flow sensor can be left 
active to facilitate patient triggering and synchrony until the ventilator flow sensor 
measures exhaled minute v olumes of 1 5 L7niin. Tidal volume measurements by the venti- 
lator flow sensor are erroneous or absent and a supplemental monitor such as the Co^smo 
plus should be utilized- Once ihe flow sensor is removed. IMV ventilation u ith heliox can 
be provided. More research should be done evaluating the ability of the ventilator's (low 
sensor to accuratelv delect neonatal inggerim: efforts w ith heliox gas mixtures OF-02-049 


Andrew l.amparxk RRT . Kathleen Dcakins RRT, 

Timothy Myers BS RRT. and Robert Chathurn RRT. PAARC. 

Rainbow Babies & Children's Hospital, Cleveland. OH. 

InlrodiK'linn: Infants with Respiratory Distress Syndrome (RDS) require mechan- 
ical ventilation due lo physiologic abnornialilies thai cause reduction m lung 
volumes, lung compliance, lung pcrfusiim and alveolar ventilation despite 
increased work of breathing. Successful weaning and cxtubation Irom mechanical 
vcnlilatitin is dependent on the reversal of the clinical manifestations of Rf3S and 
ihc ability lo adequately support spontaneous vcniilaiion. The purpose of this study 
was to assess the causation and timing t)f cxlubation failure in neonates with RDS. 
V\'e hypolhesi/cd thai both the exluhalion and rcinlubalion rales would be higher 
<m the day shift (7ani-7pm) versus night shift (7pm-7ani). 

Mflhods: Data were collected from November 1. 2001 to March ^ 1 .2(H)2. on all 
intubated patients in the NICU weighing <1500g. Upon cxtubation. staff membcrN 
recorded ihc palienl's gestational age. weight, date and time, l-or cases requiring 
rcinlubalion. dale, lime, and reason for reintubations were recorded. Reasons lor 
leintubation were classified as ainvav problems, uncontrolled secretions, 
respiratory acidosis, apnea and/or bradycardia, or respiratory distress characleri/ed 
by gRiniing. Ilaring. and/or retractions. Rules were compared with Chi-Squared 

Results: There were 1 20 extubations among 57 patients (average 2. 1 
cxtubalions/patieni). ."Xpneas. bradycardias, and respiratory distress accounted lor 
90V( of the reinlubalions. Airway problems (69f ) and respiratory acidosis (49( ) 
were less common reasons. Data below are expressed as events per 100 ventilator 

^iny^ |:ind C/ nf IoT.tIj 



(;//('/' t'lcdivf cxruhaiion 

after lucidenia! extuhution 

wiihiii 24hr\ 








1.19 (5?^f) 

1.-54 (56^r I 

after 24hrs 1 .33 0.70 ( 53*^^ ) 0.63 (47^;; ) 











Conclusion: Although the cxtubation rate was higher on the day shift. 

the reiniuhation rate was ihc same for bolh shifts. More than half 

(55Cf ) of the reinlubalions were due to accidental cxtubation. OF-02-051 

Ryan Gnjcbcr - . Osjuma Dahhagh - . Andrew McKibbcn -'. Departments of Child Health". Respiru- 
lory Care-, and Internal Medicine'. The University of Missoun-Coiumbia. Columbia. MO. L'S.A 

INTRODCCTION: Interest is growing regarding the applicauon of helium-oxygen (helioxl 
mixtures dunng mechanical veniilaiion. While the beneficial effects of heliox derive pnmarily 
fmm lis decreased density, resulting in decreased rcMsiancc loairtlow. these same physical prop- 
erties could have a significant impact on veiHiblor luiKlmn However, little invcsligjliun has 
been undenaken to define these etfeci-s. panicularlv in veiildaiors commonly used tor pediatric 

METHODS: We investigated the effects of heliox during volume and pressure ventilation on 
the function of 4 pediatric ventilators, the Bird VIP and VIP Gold and the Siemans Servo WflC 
and Servo 3l)(). Heliox was administered as an 80:20 mixture of helium-oxygen through the air 
inlet of the ventilator Tidal volumes (Vji or inspiratory pressures were chosen to deliver Vi^of 
211-23(1 mL durmg veniilaiion with an FiO: of 1 0. FiO; values of 0,2. 0.4. 0.6. 0,8. and I () were 
tested. Inspiratory Vy displayed on the ventilator (displayed Vj) was compared with ihe inspira- 
tory Vx displayed dunng veniilaiion with KKW oxygen (expected Vt Dh)- Delivered V-j was 
measured with a Neonatal Bicorc connected lo the side port of a "bag-in-box" spirometer, mak- 
ing measurement-s independent of gas properties. This volume was compared with the Vy deliv- 
ered during venlilaUon with 100'^ oxygen (expected Vto^j), For each ventilator, rauos of dis- 
played Vr or delivered Vj/expected Vyio,,,, i>.|,al each FiO; were calculated and compared 
with a Kruskal-Wallis analysis of vanance. A p value <0.05 was significanu 

RESULTS: All four ventilators functioned in the presence of helium. Tlie delivered FiO; was 
less than set FiO; with the VIP, VIP Gold, and Scrxo 900C. During volume veniilaiion. V [ dis- 
played were decreased in helium with the VIP Gold (4'/;. p<OfX)l i but were unaltered with ihe 
VIP. Servo 900C and Scrxo 300. Delivered Vj mcreascd in helium with the VIP (87^ ). VIP 
Gold (82^ ). and Servo 900C (.M** ) ip<0.(HK)l ). In contrast, delivered Vy decreased 12'S in 
hchum with the Servo 3(K) (p<0.001 j. 

Dunng pressure ventilation, Vt displayed were dccrexscd in helium with the VIP (32''.f i. 
VIP Gold ( 36<S ) and Servo 900C (18^) |p<0.UOOI ). Vj displayed mcrcased 8Vr m helium wilh 
the Servo .^00 (p<O.OOOI ). Delivered Vy increased in helium with the VIP (28'^). VIP Gold 
(17'*) and Servo 90OC (6*^ ). Dehvered Vy decreased ft'r m helium with the Servo .3(K) 
(p<0.005) Foral ventilators. Ihe magnitude of change in V] displayed wa.s increased and Uial of 
Vj dehvered was decreased compared to during volume ventilation. 

DISCUSSION: While each ventilator functioned in helium, the actual volumes both displayed 
and delivered were significantly altered by helium. Tliesc cffccLs were both ventilator- and venti- 
lation mode-specific and are most likely relaied lo the gas delivery system. Ventilator parameters 
and Vx deUvery were least affected by helium in the Servo ."^(X). Additionally. V i delivery was 
affected less durmg pressure-conlrolled versus volume-controlled ventilation, suggesting that 
pressure-controlled modes may be more desirable when ventilating with heliox. Further study lo 
determine the presence and/or magnitude of these effects in a branched lung model uouldbe rel- 
evant and V aluable. _ ^ 


\\ I krkcnh(isL.h ^ . R\.in Grueber - . Osauma Dabbagh - . Andrew McKibben '. Departmenis of 
Child Hciillh'. Respiratory Care-, and Inlcmal Medicine'. The University of Missoun-Columbij, 
Columbia. MO. USA 

INTRODUCTION: It is well recognized that alterations in gas density can impact ventilator and 
pneumotach function. While ii has been assumed that the small difference in density between 
nxmi air and ItX)^ oxygen would have negligible effect on these functions, we have been unable 
lo find published data to confirm this. 

METHODS: We investigated the effect of Fi02 (0.2, 0.4. 0.6, 0.8. 1 .0) on delivered tidal volume 
( Vi I during volume and pressure ventilation in 4 pediatric ventilators, the BIRD VIP and VIP 
Gold and ihe Siemans Servo 900C and Servo .'^tKl. During volume ventilation, set tidal volumes 
I Vj I ranged from 20-250 rnL. During pressure ventilation, inspiratory pressures were chosen to 
deliver lidal volumes in ihe same range. Inspiratory Vj's displayed on the ventilator (displavcd 
Vt ( v^ere recorded and compared with the inspiratory Vy displayed dunng ventilation wiih ri>tim 
.ur (expected Vy dh'- Actual delivered Vy's were measured with a Neonatal Bicore connecled in 
the side pon of a "bag-in-box" spirometer, making volume measurements independent of 
inspired gas properties, This volume (delivered Vj) was compared to the Vj delivered by the 
ventilator during veniilaiion with room air (expected Vypj-i). For each ventilator, ratios of 
displaced Vt and delivered Vy/expected Vy ,[),i..t ivn *crc calculated and compared at each FiO; 
with a Kmskal-Wallis analysis of vanance. Ap value <0,05 was considered significant. 

RESULTS: During volume ventilation, there was a small decrease (2.2%) in displayed Vt with 
increasing FiO; with the VIP Gold. Displayed Vy was unaffected by FiO; with the VIP. Servo 
ytK). and Servo 3(XI ventilators. There was a progressive decrease in delivered V y with increasing 
FiO; with the VIP (6.5<>J J. VIP Gold [5A''A ), and Servo 9{K)C ( 13':"'^ ) (p<0.(K)l ). This 
was present over the range of tidal volumes measured, and is similar to the difference in density 
beiween room air and lOO'J*^ O; ( 10,8'S^). Delivered Vy was unaffected by changes m FiO; with 
ihe Ser\o 3(X) ventilator. 

During pressure ventilation, there was a small but significant incrca-se m displayed Vr with 
increasing FiO; with the VIP (l.O';* ). VIP Gold (4.5'* ) and Servo 900C (6,3^^ | ventilators 
((x:(l.(M)5). In contrast, displayed Vy decrea.scd 3.2'i with increasing FiO; with Ihe Servo !l(Kt 
venlilalor (p<0,(X)l ), As with dunng volume veniilaiion. delivered Vy decreased with increasing 
FiO; with the VIP {Ay^T, |. VIP Gold (2.4^^ ) and Servo 900C (2..^"^ I ventilators (pcO.OI ) How - 
ever, ihe magnitude of ihiv decrease was less than during volume ventilation. There v^as no sig- 
nilicanl effect of FiO; on actual delivered Vy w iih the Servo 300 ventilator, 

DISC'l'SSION: This is the first study to demonstrate a decrease in lidal volume delivery- v^ith 
increasing FiO; in 3 of 4 ventilators commonly used in pediatric patients. Tliis v^as both 
ventilator and ventilation- mode specific. Changes were most pronounced dunng volume venUla- 
tinn but the effects did not appear to be sensed by the veniilaior. The absence of an effect with the 
Servo ifH) is most likely a result of its gas module design. While the clinical significance of ihis 
ettecl is likely minimal in most scenarios. Ihe practitioner should consider this when making 
Lirgc changes in FiO; OF-02-063 

Respirator-i- Care • September 2002 Vol 47 No 9 


Satiirday. October 5. 12:30-2:25 pm (Rooms 18-19) 

Jim KL'cinin BS. RRT. PAARC . Ralph A, Luyo. PlianiiD. Pniiiiirv Children's Medical Center. 
UiiivL-rsity of LUah Collcpc of Phaniiacy. Sail Lake Cily. lUali, 

Inlrodudiun: Moniioring iidal \olunics ( Vt) m a li mi: -cycled, prossurc-limiled mode has greatly 
impro\cd ihc managcmcnl ol \ctuilated rieuiiales. ihereby prcvenimg lung injury and possibly 
Bl'l) However, increased reliance upon nioiiitonng Vi requires thai ihe accuracy of the llovv sen- 
sors be assessed, We sought lo \,didale \'l reported on the Bird (lold and Drager Babylog infant 
ventilators by comparison with pli.-lh)sinogr.iph\. which is the gold standard for Vt measurement. 
Methods: The Viiallrends bod> plethjsmograph isoleiie is designed lor infants <3 kg and uses a 
single screen {,^00 mesh stainless sicel) low resistance pneuinotachomeier to measure volume dis- 
placed within a closed system. The Bird Ciold and Drager Babylog ventilators were compared 
using a neonatal circuit, a .I.O-nim endotracheal tube, and an IngMar neonatal lest lung. New flow 
sensors were used lor each experiment Two ventdalin condilions were seiecied: Condition I ) 
time-cycled, pressure limited AC. rate 25. pressure 21) cm H^O. 1 1 0.3 sec and a flow of 6 LPM; 
Condition 2) time-cycled, pressure limited AC. rate 211. pressure 30 cm H^O. Ti 0.4 sec and a 
flow of in LPM, I'ndereach condition, experiments using V-iOz = 0,21 and 1,0. and relative 
huntidity = 2Kc and lOO'v were conducted. The pleihssmograph wa.s calibrated prior lo each 
expenmeni according to manufacturer's speci Heat ions. Lach ex(>erinient wa.s conducted using 20 
ventilator breaths. The Vt reported for each ventilator breath wa-s compared to the corresponding 
Vt measured by plethvsmogr.iphv \'l was adjusted ft)r the Iwal altitude of -5000 ft. according lo 
conversion factors pro\ ided h\ cicli \ciililali'r manufacturer. Data were compared using 
Sludeni's t test or Mann \S hilnev L' icsi Results: Vt for holh ventilators and plethysmography 
are reported ;uid compared in the table Conclusion: Ventilator's accurate measuring and report- 
ing of tidal volumes is extremely uiiportant. as it is often an integral part of ventilator 
management. In this study the Drager reported the volumes more accurately Ihan the Bird Gold 

Ti'st Cundilion 







:i'; o:/ 

AiilbiL-rll HutnidUv 



11 2 t 

').S((l «i 

9 '< Id.dSl 


\[iihLL'n[ ttuiliidllv 


'J,4 (11.(10) « 

25.2 t 

9,1 1(1.14) + 




7 S (l(07l 

X S 1(1.00) • 

15.8 t 

9.6 1(1 141 i 



KHI'. 1)2/ IIHI'> 

7 7|ll Ul 

S .5 1(1.(171 * 


S 4 (d 2Kp 



I t'st Condition 

:i'; 02/Arat>ienl 

i: Jin:si 

14 s 1(1.0(11 - 


14 2 ill(17i 

146(0(1(11 i 

"( 2 

mil', {>:/ 

\iiihiLril HunildU\ 

i: 1 ii)i5i 

14.6 ((1(171 - 

20.1 t 

14 2l(142i 



:i'. n:i i(Ki<:f 




') 5 t 

14.6(0 l.Sl J 


6 6 

Kill', o:/ 100'* 



13.8 (0.211 • 

12,() t 


1.5 0(0,081? 

2 4 

P<0.05, Plelh vs. BIRD t P< 0,(15, •?, Deviauun. BIRD vs. Drjger i P< 0.05, Plelh \s. Dra»er 



IN pre,s.slirecontrolli-:d ventilation 

J.iho Oi^ksdii. KRI . Ruben Chalhum RRT, l-.WRC .inJ Timolhy R. Myer. B.S, RRT, 
Rainbdw Babies A: Children's Hospital. CIcvekuKJ, OH. 

InlrtMJuctiiiii. The jioal ot iiieehajtical ventilation is adeqtiale gas exchange w iih ininioial 
luni! tissue daniajje and inininial eireulatory disturbance- Tidal volume (Vyl dunny pres- 
sure eontrulled modes de[iends on the balance between respiratory svstcm ;uid ventilator 
circuit compliance lie, compluuiee of tubing matenal plus compressibility of gas i. Tradi- 
tionally, circuit manufaetua'rv have prtxluced tha-e ciauits (neonatal, pediatnc and 
adultl. Fisher-Paykel has developed an "adult" ventilator circuit (low compressible vol, 
ume lossi that effectively delivers safe pediatric Vj eliminating the need for a special 
pcdiatinc circuit. Now Fisher-Paykel has developed a prototype "neonatal" single-limh, 
heated-W'ire. v cntilator eireuit for the neonatal markel. This neonatal circuit is made of Ihe 
same matenal that the adult circuit. We hypothesized no signilieant difference in deliv- 
ered Vj between the Fisher-Paykel and our stamUtrd .Allegiance cia'Uit under simulated 
time -cycled, pressure limited ventilation conditions. Methuds: Circuit compliance wa.s 
mea,surtd by connecting 4 circuits of each brLind to a pa-ssua manometer and iniected 
calibrated volumes (."^(1 mLl. To test our hypiUhesis ol a no signilieant diffca'nce in deliv- 
ered V r at similar scM peak pressures. 5 eia^uils of each brand w ere tested under simulated 
ventilation using ;ui hilrasonicsTest Lung (C=lcmH;0/mLl a.s our patient. .An Infant .Star 
and a Fisher-Paykel humidifier served as our ventilator system. Randomly set PIPsi id to 
48 cmH20 2 cmH^O incremenlsl were tested with a'sulting exhaled volumes ineasua'd 
by the Novametrix Como-t- monitor. Mean difference in Vr wa-s compared with a t-test. 
Kesultii: Pressure volume plots y lelded circuit compliances of 1 . 1 .1 (± 0.0.^) emH:n/mL 
( Fisher-Paykel 1 and II.W l ± (l.ll 1 1 cmH;(l/mL ( Allegiancel- Volume deliv ery was not dif- 
ferent between the two circuits with the exception of the two lowest levels of pressure 
conooh 10 and i2cmH;0: p = 0.021. The figure below shows mean±SD: 

ft.a.MC CWWCH 

ConcllLsion: The new prototv pe neonatal circuit by Fisher-Pay kel demonstrated compa- 
rable tidal volumes to our standard Allegiance neonatal ciauit While the Fisher-Paykel 
circuit delivered statistically significant higher tidal volumes at the two lowest levels of 
pressures tested in this study, a I niL difference is probably elinicallv irrelevant in most 
'"-'""^"^^ OF-02-102 

RIAN GRAPHICS MONITOR. Brian Glynn. BS RRT . Raymond Malloy. 
BS RRT.Willtam Buchcr RRT.Thtimas H. Shaller PhD, Wendy S, Sturtz, 
MD, Su/anne NL Ttitich. MD, Ja\ S, Greenspan, MD, Depannienis of Pui- 
nionan Care and Neonatology, Thomas Jefferson Universitv Hospital 
(TJUHl. Philadelphia, Pa, 

BACKGROUND: At TJUH. the Sensomiedtcs ,1I(K)A High Frequency 
Oscillator (HFOV I is used lo improve ventilation and oxygenation in 
neonates with respiratory failure w ho have not responded to conventional 
modalities. To optimize lung protective strategies, the goal is to achieve tidal 
Milumes of 4-6ml/kg and these ;ire conventionally thought to be less than 
physiologic dead space volume. .As the Sensoniiedics .1|(X)A Oscillator does 
not have in-line monitoring, an external monitor was utilized to track the 
intaiits' tidal volumes during routine care, and these values were compared, 
HYPOTHESIS: Tins study was an attempt to validate Ihat tidal volumes are 
less than dead space v olume. METHODS: Five infants on the 
Sensomiedtcs .^KKIA HFOV vvilh chronic lung disease and without air leak 
were monitored. Tidal viilume and tidal \ (ilume per kg were recorded using 
hot-wire anemomelry ( Florian: .^cutronic Medical Systems). The range of 
HFOV settings were MAP (12-14 cm HsO). amplitude ( 1 8-40 cm HoO), f (8- 
1 2 h/). and inspiratory time (0..\^ (.RESULTS: 


weight (kg) 

mean tidal 

mean tidal 



tidal vol. 


dead space 
































eslimaled physiologic tidal volume-7-8 ml/kg 

estimated deatl space v olume- 1/.^ of physiologic! 2..^ ml/kg) 

CONCLUSION: The above data indicales thai incasured tidal volume/kg 
during' HFOV is equivalent lo it not greater tiian e\[x,'cled dead space 
volume in 4 out of 5 patients. Although the udal \oiumes are greater than 
dead space \(tlume. the tidal volumes remain below the goal of 4-6nil/kg to 
achieve optimal lung protective strategies. Tlie Florian Graphics Monitor 
may be useful in oplirni/ing ventilation during oscillation, and ma\ he useful 
in reducing the need for arterial bUuxl ga.s draws to assess ventilator-patient 
interaction. OF-02- 1 08 


Jim Kcenan BS. RRT. FAARC . Primary Children's Medical Center, Salt Lake 
City. Utah 

Intruduction: When ventilating spontaneously breathing neonates it ise.xtremely 
important tor patient conilort and s\ nehron\ for \cntilalor hrealhs to be deli\ered as 
quickly as possihie. Ventilator manufacturers reler to this as response time and many 
ha\e different ways of calculating and reporting it. For our purpose, we defined 
response time as how quickly a ventilator begins to deliver flow at the endotracheal 
tube after a patient's spontaneous breath effort is detected by the venlilaUir, We 
sought to measure response time of the Bird Gold and the Drager Babylog, Meth()d: 
The Vilaltrends plelhysmograph isolette is a closed system that measures volumes 
and pressures displaced v\ ithin the s) stem. The Vilaltrends uses a diflerential pres- 
sure transducer lo measure pressures and uses a single screen (3(HJ mesh stainless 
steel I low resistance pneumotachomeier to measure volume. The plethysmograph's 
pressure transducer is w\ed into the ventilator circuits proximal pressure line distal 
to [he wye piece. This allows graphic and wavefomi analysis cm ventilated infants 
<3Kg. The Vilaltrends computer package has ihe ability lo measure and analyze 
graphic wavefomis in milliseconds. The Bird Gold and fJrager Babylog ventilators 
were used with neonatal circuits venlilaiing an Ingmar neonatal test lung in separate 
tests. New flow sensors were used for each experimenl- The ventilator settings used 
were: time cycled, pressure limiled AC. Pressure 25 cm H2(). rate 20. flow 6 LPM. 
Ti (}.,^5 sec. and a trigger sensili\ily of 0.3 LPM. .A small plasiic l-piece was inserted 
between a .3.0 mm endotracheal tubes connector and the lube iiscll. The t-piece was 
connected lo a 10 cc Hans Rudolph syringe. Fish line was attached to ihe synnge 
plunger and was run out ot the closed plelhysmograph. Hie plelhysmograph was 
calibrated betore each lest as per the manutacturer's specifications. A spontaneous 
breath was simulated w hen the line attached U) the syringe plunger was pulled. 
Twenl> spontaneous breaths were recorded and analyzed for both ventilators. 
Results: To detenninc response lime we measured Irom the \'ilalirends graphics at 
ihe point ot negative pressure delleclion. caused by our sponuineous tngger, it) the 
tlrsi rise ilelecled in flow. Response time results are reported in the table. 
Conclusion: Response time is an important component for patient comfort and syn- 
chrony when choosing a ventilator for neonates. The '"'< dilterence indicates that the 
Drager response time is 2S shorter than Bird Gold, however, the actual time differ- 
ence IS 0.01? sec. Two qucsiions that require turther unesligalion are; 1 1 is a differ- 
ence ol 0,015 sec, clinically significant betvveen two devices,' 2) What are appropri- 
ate response times of ventilators for spontaneously breathing neonates? 


filr.1 CM 

(),().S4 > 

Dracer Bah\ li> 

OXm see 



P<().(K1,S Mann-Whitncv V 



Respiratory Care • Septembf-r 2002 Vol 47 No 9 

Saturday, October 5, 12:30-2:25 pm (Rooms lS-19) 


AnnComtv. Ph.D. RRT . R Acker RRT. C Buchler RRT. V Newman MD, Respiratory 
Caie Dcpanment. Division of Pediatric Inlensne Can;, Children's Hospital Oakland. 

Background : 4 patients with idiopathic scoliosis, treated in the |X!stO[X.'rjIive pemxi 
with High Frequency Chest Wall Oscillation (HFCWOl were reviewed relrospivti\eK- 
All four patients were in the Pediatric ICU and had undergone [Xistenor spinal fusion. 
Radiographic re'\ic\\ of therapeutic ;ur\\ ay cle;uancc was uiideitaken. 
Objective : To review the hospital coun,c ot 4 adolescents w ith significiint airway 
clearance issues and/or atelectasis and pleural effusions. 

Method : We choose HFCWO w ith the VEST System in patients w ith ;ui inadequate 
cough due tt> ptist operativ e pain, an artificial airway for ventihitt)ry support or 
neuromuscular disease. All paticnl.s were ta'ated for 20-30 minutes w iih a Pre'ssure + 3 
and Frequency of 1 5 HZ. Treatntent> were repealed every 2-4 hours. 
Outcome : Paiieni ime wai treated on day 5 post operatively for persistent Left Lower 
Lohe I LLL) intllmite vs. atelectasis after failing standard positioning and postural 
drainage techniques. Started on the VEST every 4 houn- and then increa.sed to every 2 
hours for one day . Repeal x-ray the follow ing day showed improved aeration LLL. 
Palieni two wa-s treated on the 3"" day post operatively for Right Lower Lohe (RLL) 
infiltrate vs. atelectasis with small right pleural effxision. VEST treatments were initi- 
ated every 4 hour>. .Mter 6 treatments, repeat x-ray show ed increase aeration of the 
RLL. Paiiint three initiallv showed normal aeration post operatively while ventilated. 
After 14 hours, x-ray showed opacification of left hemithorax with bronchial "cut off 
sign, suggesting collapse due to mucous plugging. .After increasing PEEP, to 8cm. 
there- was no improvement. .Aercisolized D-Nase was administered in conjunction with 
a VKT tR-atment, and this was followed by four VEST treamients given every 2 hour;. 
Thereafter repeat x-ray showed dramatic inten al improvement in left lung aeration with 
peisistent left pleural effusion and minimal residual LLL atelectasis. 1 5 hours later 
repeat x-rav show ed almost complete resolution done.of atelectasis w ith increased 
Right Upper Lobe I RULi atelecatasis. Patient was exiubated and repositioned w ith 
head to 45 degree and contunued VEST treatments. Follow up x-ray showed improv ed 
aeration of RUL. There was still a small residual left plueral effusion with minimal 
atelecatsis in the LLL. Patient four was started immediately post operatively on VEST 
everv 4 hours, while on ventilatory support.. The frequency of u>;atments remained 
every 4 hours for the first 4 days post operative. Radiographic review dunng this 
patient's stay in the Pediatric Intensive Care never showed infiltrates or atelectasis. 
Conclujiion : .Although only four patient's were initially studied we arc confident that 
HFC\\'0 w iih the VEST is a chnically safe and effective airway clearance technique in 
ventilated or post extubated patients that have undergone spinal fusion, and suggest that 
further studies should be OF-02- 1 56 

TION PNEUMONITIS: A CASE STl'D^ . Ri)liona L. Holes BS. RRT. RN . Su/jnne M Dumrng BS. RRT. 
Kairn Bonn AS. CRT. Vinay Nadkami MD. The Children's Hospital of PiiilaJeiphia. Philadelphia. PA 
A 9-nionlh s/p .^1-wcck premalurc iniant presented with lever, somiung. diarrhea and siaulalnrv shcick He 
required voluine rcsu-scilauon and tracheal inlut)at]on in the emergency depanmenl. He was noledio have 
fonnula beneath Ihc voc-jl eords on Iraeheal innibation with a4.0 uncuffed Iracheal lube Twenty four houis later, 
Ihc patjcnl was supported wilh a Siemeas Servo .100. Pressure Regulated Volume Control (PRVC). FiO; 35- 
50^. Vt lOO. RR 2-S. PEEP ftcmHsO. Ti .75 seconds and a peak inflaung pressure of 38-41 cmHsO He was on a 
pancuronium and lentanyl infusion, with inlerminem lorazepam sedation and managed with permissive hypcr- 
capnea targel of PCO: SU-Wltorr In addition, he requued 10 mcg/kg/min dopamine, eryslalkud boluses, and 111 
mWsg PRBCs in a 24-hour penixj lo treat low blood pressuniTiypoperfusion CXR w as eonsislent with aspira- 
uon pncumonuis and ARDS During the course of the day. the patient had an increasing oxygen and ventilation 
requirement- He was ventilated using a prulective lung strategy of 6mt/kg Vt lo limit the peak intlaling pressure 
lo 35 cmH;0, PEEP maneuvers determined a best PEEP of 10 cmH;0 
Blo«xl cas results were as follows 








VI liK)ml,RR2^.PEEP6cmH-0, FiO^ I 0». PIP?b^l cmH^O 







VI KSml. RR 22, PFEP W .mH^O, V\<h 35. PrP 35 37 ^jmHsO 

7 15 






VI S5ml. RR 2H. Peep KUmHjO, KiCr 35, PIP 35-37 cmH:0 

7 32 






Despite ihe ubilii> lit iithieve itccepuible blood gjsc-v on conventional vcniilation. we tran.Miioned the patieni lo 
the Scasormedit HFOV 3 1 OOA. as an early intervention, rather ihan a rescue strategy This dctiMon was made in 
anticipation or the need for increasing ventilatory suppon and V/Q mismatching, inanatiempltommimi/e latro- 
geniclung injury. 

Biixxl ya.s results on the HFOV were as follows 

HK)\ settinKS 







Pjv^ ^^ Dc:lijP>^t.mHiO, Freoueni.\ 7 H/, FiO^ 40. Ti ??T 

7 }l> 




♦ 8 


Paw 25. Delta P 55 i;mH:0. Frequency 6 Hi. FiO: -10. Ti 3-^T 




34 7 

y 1 


The patient was maintained paralyzed and sedaled on the Sensormedic HFOV for lour days and subsequently 
transitioned to the DragerEviu 4 mAPRV.Ph,^ .15. Pi.„. 12.1^,(^2 5 seconds. T^^ 1,5 seconds Following 
transition to APRV. paralysis was discontinued. 

Blood gas results were as follows 





HO J. 



f>.,,s. 35,P,„. 12,T,„.„,:sec,T.„. 

1 sec FiO- 45, Vl,^ 1 10ml 

7 IK 




I 1 


'.,., .'5,P... I2,T,„,., 2sc.,T,..,. 

1 -cc, Fif)^ 25. \l^,n 140 ml 

7 5fi 






\.,h -Hi, Pi.,. i:.T.,,s 2scL,T, . 

Ncc, f-iO- 25 Vi^,^ 120ml 

7 50 




4 3 


Ph,.-,2h. Pi„»yT^,.r,2sct. T,,.. 

sec.FiO- .H». Vl^„ 100 ml 

7 4X 




5 « 


Ph,ph24.P,,™9.T,,,, 2scc.T,,„ 

1 sec. FiO; 30. Vt^in "JH ml 

7 42 






The patient was iransiUoncd to SiMV with AutoFlow per physician preference and subsequently weaned to extu- 
balion in three days Thepatieni was weaned frDmtmygenoneday following exiubation 
Discussion; Many strategies can minimi/c iatrogenic lung injury a.ssocia[ed with aspiration pneumonitis and 
ARDS. Early intervention with altcmaUvc modes of ventilation (HFOV and APRV) can be cITeclive, HFOV 
with paralysis/scdaiion facilitates lung recruilment and early transition lo APRV allows return to spontaneous ven- 
tilation without paralysis and derecruitment of alveoli. This venlilalory strategy resullcd in a positive patient out- 
come and ma\ iv a useful management strategy Q' '02-165 

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Circle 103 on product informotion cord 


Respiratory Care • September 2002 Vol 47 No 9 

AenChamber Plus" VHC: The Gold Standard 




• • • 

AewChamb'er • 


Formulations Studied' 

Albuterol, CFC and HFA 

Albuterol and Ipratropium 
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Saturday, October 3, 1 2:30-2:25 pm (Rooms 20-2 1 ) 

C'ARF HOSPITAL W FrciKh. MA. RRT . K Bauer. BS. RRT. Lakeland Comiiui- 
iiii> College. Kirtland. OH 

Direet nbvenation suggests thai the inslillation ot a normal sahne (NSI) hoius prior 
to endoiraeheal suctioning is connnon practice in niosi iniensi\e care units. Plus 
practice persists despite the tact that there is \er> little ohjectuc data suppoiling its 
use or documenting its ett"icac> . Funher. several recent studies h;ive documented 
poicnlial hamitul ettecis associated v\ ith NSL Therefore, because e\cn llie most 
supportive studies ha\e been, at best, ambivileni. clearly the use ol NSI should be 
limited it not completely eliminated from clinical practice. However, before educa- 
lors and clinical administrators can discourage NSL they need to understand how 
much it is used and wh\ It used by practitioners. This knowledge is best gained 
through surveying the practitioners themselves. 

.A survey consisting of 8 questions was distributed to 76 respiratory therapists (RTs) 
employed by a large acute care hospital. A tola! oi .^3 surveys were returned. The 
first four questions pro\ ided background data about the practitioner respondents, 
while the last Uuir questions asked the practitioners how often he/she does NSL how 
much NS is t\picall\ uistilled. why it is done, and where it was learned, hi addition, 
for comparison purposes, a similar survey was administered to the nursing staff in 
the intensive can.' units. However, those results are not presented here. 

Ninety-three percent of the respondents were RRTs. Sixty-three percent reported 
their highest education level being an AD. while 27'7f had a BS or higher. 
Experience ranged from \2'^7< with less than two years to Z-i*^} having more than fif- 
teen \ears. Si\ly-se\en percent reported that they perform NSI occasionally while 
24'^ reported perfoniiing NSI routinel) and I2S performed it rarely. Eighty 
percent reported instilHng three niL or less, while 1 3*^! instilled 3-4 niL. Fifty- 
eight percent reported that iheir principal reason for NSI was to 'liquify the mucus." 
Forty-five percent listed "lubncate mucus' as their principal reason for NSI. Six per- 
cent hsted 'stimulate cough" as their pnncipal reason. Sixty percent reported learn- 
ing NSI in school. The remaining responses were farih evenly distributed among 
established policies, published literature and watching other practitioners. There 
were no correlations betvveen NSI practice and either education or experience. 

Clearly, in this particular facility NSI is common practice, based on the survey 
results. Furthermt>re. it is a practice that cuts across boundanes set by education and 
experience. It is also clear that the RTs who responded have a poor understanding of 
NSI. as the only study to document any positive benefit concluded that the principal 
mechanism of NSI was cough stimulation. Finally, educators might take note of the 
fact that the majority of respondents reported learning NSI in school. Ob\iously. 
this study is very limited in that it only looked at a group of RTs in one facility 
However, based on observation and discussion with others, the authors believe that 
these results are typical of the RT workforce at large. OF-02-058 

VViiliani French. MA. RRT. Lakeland Coininunity College. Kinland. OH 

In recent yciirs. the practice of performing routine ventilator checks (VC) has been ques- 
iioned. Nc\ertheless. the practice persists in most acute c;u"e hospitals, usually every two 
to four hours, and when venlil.iioi^es are made. GencralK . .i \ciiiilator check con- 
sists ol a-cording data such as vcniilaioi settings. patienty\enlil.iini inlcrlace data (e.g. 
actual a'spiratory rate, return volume, peak inspiratory pn-'ssure. etc, I. and basic 
assessment data (e.g. heart rate, ba'ath sounds. SpO^. etc.). Although there is little d(x:u- 
menlation of need, respiratory therapy depiirtmenls probably a-quire routine checks for 
the following reasons: 1 ) b;Lsic documentation of satisfactory ventilator function, and 2) 
ensiiR- thai a therapist visits the bedside on a timely basis. However, il is unlikely thai 
administrators are awans of how much time is actually spent in peribnning a routine VC. 
Thus, the purptJse of this study was tti see how long it takes to pertt)rm a simple VC. 

Ventilator flowsheets were obtained from several local acute care hospitals. An intubated 
manniquin was placed on a 7200 ventilator at the following settings: rale 1 2, Vi 400. Ot 
■iiVi . PEEP +5. mode CMV. peak flow .SO Lpni, square wave, The simulation also had a 
cardiac monitor displaying a regular rh) thm and rate, and audible breath sounds. Five 
respirator) therapy students near graduation and previously familiar with the particular 
How sheets and the process of pertbmiing VC were recmiled. The students wea* informed 
as to the nature of the project and wea instructed to perfomi the VC as though it wea* a 
real situation. For each flowsheet, three students performed a VC. each independent of 
the other and without observing each other Each VC was timed with a digital stopwatch 
without the student being aware of the time. The students were sequenced so that no stu- 
dent perfoniied more than one VC on the same flowsheet. In addition, for the second two 
sets of checks, the ventilator settings were slightly altered. 

The first flowsheet required a total of 26 separate items that had to be observed and 
recorded. The mean time retjuiad to iKcnniplish this was 4, 1 minutes. The second flow- 
sheet also required the a'cording of 26 separate items. The mean lime required to accom- 
plish this was 3.3 minutes, The third Oowsheel required the recording of 2 1 items of 
intomiation. The mean time per VC was 3.9 iiiinutes. When the three means were aver- 
aged together, the time was 3.8 minutes. 

Ob\ iously. this study was very limited since it was done under simulated conditions in a 
quiet laboratory. However, because of the stable nature of the simlated environment and 
the fact that the patient/ventilator interface wa.s ideal, the mean time recorded probably 
represents the absolute minimum time required to perform a VC. From the perspective of 
time management if we assume thai the average VC requires a minimum of about 4 min- 
utes to peribmi, then a therapist assigned five ventilators in a typicaJ ICU would spend at 
least 2() minutes every round of checks just observing and recording data. 


Roben NL Kacmarek. PhD. RRT. FAARC: De;ui R. Hess. PhD. RRT. FAARC. Mas- 
sachusetts General Hospital and Han ard Medical Schtxil. Boston. M.A. 
Background: .Administration of aerosol antibiotics has increased in recent years, which 
has raised concems related to caregiver exposure. To our knowledge, there are no pub- 
lished standards related to caregiver protection during aerosol antibiotic administration. 
The results of an informal sur\e\ re\ealed a \:ineiy of practices in hospitals ;iround the 
United States. Hypothesis: A measurable amount of paniculate is present in the room dur- 
ing aerosol antibiotic therapy, but achons can be used to minimize caregiver exposure. 
Methods: .A Puntan-Bennelt S40 \entilator (Tyco. Carlsbad. CA) was attached to one 
chamberofadual-chambered test lung (Michigan InsUTiments. Grand Rapids. MI), Venti- 
lator settings were Vj U.5 L. rate 16/min. I:E 1 :2. A lift bar placed between the chambers 
simulated spontaneous brealfung of the second chamber which was connected to a filter 
(Hospitak. Famiingdale. N^'i that was in tum connected to a Pari nebulizer (Pan LC D. 
Monterey. CA). One \ial (? inL, 3(X) mg) of Ttibi (tobramycin solution for inhalation. 
Chiron. Emen, \ ille. CA) was placed into the nebulizer. The nebulizer was operated with a 
flow of 8 Umin until no further aerosol was produced. The anmunt o( particulate in the 
room was sampled using an 8-stage cascade impactor (.Andersen Mark IL Symra, GA). 
Particulate was collected on glass fiber media subsU"ates and the amount of particulate 
deposited on each stage was determined gravimetric ally ( Mettier PB 153-S balance). The 
cascade impactor w as placed 5 ft from the site of aerosol generation. The following condi- 
tions were tested in a patient axim: 1 ) a baseline 1 hr siuiiple with no aerosol generated 
dunng the sample penod. 2) 1 hr sample with a simulated Tobi treatment at the beginning 
of the sample periixl. 3) a simulated Tobi treatment with a I hr sample initialed 30 min 
after the completion of a simulated Tobi u^aunent 4) I hr sample with a simulated Tobi 
irealmeni during at the beginning of the sample period, with a respirator mask (3M 1860 
Health Care Particulate Respirator) fitted over the inlet to the cascade impactor. ?) 1 hr 
sample with a simulated Tobi treatment during at the beginning of the sample period and 
the room configured for p(:>sitive pressure. Results: During the baseline measurement w ith 
no aeaisol delucred into the room, no particulate was delected. During Tobi administra- 
tion during, y mg of paniculate was sampled and these piirticles were in the respinible 
range (MMAD 2.6 microns). When sampling was initiated 30 min after die completion of 
the Tobi aerosol. 4 ing of particulate w as sampled w itli a MM.AD o\ I 1 microns. No p;ir- 
ticulale was sampled when the respirator mask was used and when tlie nK>m vsas config- 
ured for positive pa*ssure. Conclusions: .Although a measurable amount ol respirable par- 
ticulates were sampled during Tobi administration in a standard patient axrni. caregiver 
exposure w as eliminated by use of a respirator mask or a positive pressure room. Further 
work is needed to assess other aerosolized antibiotics (e.g., colistin. amphotericin! and 
additii>nal anmi configurations (e.g.. negative pressure). „P ^^ „o« 


Susan Wiersgalla. RRT. RCP, North Memorial Medical Center. 
Robbinsdale. MN. 

OBJECTIVE: To improve post operative atelectasis with Coronary 
Artery Bypass Graft patients as determined by chest X-ray. Also further 
compare the results of EzPAP therapy with Incentive Spirometry. 
DESCRIPTION: EzPAP from DHD Healthcare combuies patient nega- 
tive pressure breathing and all of its benefits, with a positive expiratory 
pressure. Using a fluidic process, flow is augmented on inspiration. PEP 
is provided during expiration. This augmentation provides for a larger 
flow and volume with less effort than an unsupported inspiration. 
from August 2001 to October 2001 on 50 patients that were randomly 
selected to have either EzPAP or Incentive Spirometry after post op 
Coronary Artery Graft Surgery. MEASURES: Chest radiograph 
was read by radiologist. Atelectasis on chest X-ray were reviewed and 
compared on postoperative day of surgery and after chest tubes removed. 
RESULTS: The Incentive Spirometry group (n=20) showed improved 
atelectasis 259c vs. EzPAP group (n=:30) showed improvement of atelec- 
tasis 100%. This improvement was statistically significant (p<.00i ). 
CONCLUSION: EzPAP therapy has demonstrated measurable improve- 
ments in atelectatic post surgical Coronary Artery Bypass Graft patients, 
and should be considered a viable option in the pulmonary management 
of this population. 


Respiratory Care • September 2002 Vol 47 No 9 


Saturday. October 5, 12:30-2:25 pm (Rooms 20-21 ) 

MP . Patricia C. Wankuiii Ml). Shirley J. Holl RRT. Tracy I- Thurnian. 

IVdialrics. i;AMS/Arkuiisas Children's Hospilal. Liltle Rock, AR. 
Background: Work ol breathing ( WOB) for pediatric and neonatal 
patients supported on mechanical ventilation relates to both patient effort 
and response time of the ventilator. Recent advances in mechanical ven- 
tilators include incorporation of computer controlled active exhalation 
valves to improve response time thus decrease WOB. Objective: The 
objective was to evaluate the effects of an active exhalation valve on 
W(JB and the response tiine during changing inspiratory How or inspira- 
tory rise time (IRTl on the Siemens Servoi '^'. Methods: Six neonatal 
and six pediatric ventilated spontaneously breathing piglets were studied 
in pressure support (2 cm H:0). PEBP (2 cm HjO) with IRT 05!:, 5%, 
\09c and 20%, utilizing How triggering. Data were collected using both a 
computerized respiratory monitor and data acquisition system to evaluate 
differences in the duration of inspiratory effort, trigger response time, 
and any significant pressure or flow variances relating to IRT. Response 
time of the ventilator included quantification of the slope of the inspira- 
tory flow curve and the area of flow from the baseline pressure to when 
expiration began. In addition. WOB was measured. Results: When com- 
paring all levels of IRT. no differences in WOB were found in neonatal 
or pediatric animals. When waveforms were compared, we found no dif- 
ferences in the animals' effort to trigger. We also found no differences 
in slope. Conclusions: In healthy animals, since the active exhalation 
valve optimizes flow, the lack of differences with changes in IRT can be 
explained by the ability of the active exhalation valve to respond to the 
animal's effort or needs. Disclosure: Unrestricted grant from Siemens 
Medical Systems 


(PIC(.'). Imnk Miller, Kkl. Jeanine Moorhead. RRT. Cheri .Schuler. RRT, RPFT. 
MayoC'linii: Huspiial. Phucnix, AZ. 

Ilui'kt>ri>und: IVnphcrally inserted central catheters (PICC) have typically been 
m.scrtcd by physicians and specially trained nurses. In 1998, with only two nurses 
trained to insert PlCCs, our institution created a Venous Access Pntcess Impmvement 
( PI I team to evaluate the need to develop and expand the cunenl PICC tcani. The 
Venous .Access PI ic.ini considLTcd respiratory therapv as .i potenliai resource, bul rec- 
oL'iii/ed Kut jiniil.ilions license reslnetions and lack ol trjiniUL' Praeliee linutalions 
weie .iddressetl w ith the .-yn/ona Board ol Respirator) Care txamtncr,, who 
detcmiined that PICC insertion is within a respiratory therapist's scope of practice. 
Training of respiratory therapists included attending an extensive 8-hour Iheoreuc and 
practical education prognini. followed bs clinic demonstration and ctimpelency evalua- 
tion. Once both limitations had been resoKed. a core group of respiratory therapists 
were introduced as meniberN ol our PICC team in 1999, 

Method: RetAKpectively we reviewed the charts of 1.295 patients having a PICC 
inserted either by a respirator.' therapist, registered nurse, or physician for infection over 
a 2 year time frame, Respirati >r\ llierapist and registered nurse PICC insertions were 
perfonned at the patienl's bedside ulili/ing a chest x-ray to venfy pniper placement. 
Unsuccessful placement of a PICC, by a PICC team member, was referred to a physi- 
cian who inserted a PICC uulizing fluoroscopic imaging to verify placement. 

Results: Out of the 1 ,295 patients having a PICC inserted, iil were inserted by a respi- 
ralorv therapist, 790 were inserted by a registered nurse, and 168 unsuccessful insertion 
atlciiipls being ret'eired to a phs sieian for insertion. There were 7 infections (0,5'~f I 
.issoei.iled w ilh the insertion ol the PICC. 5 infections from llie 79(1 PiCCs insened b\ 
registered nurse (0,6' v 1, 2 mtecuons from the 168 PlCCs inserted by physicians (1.2':tj. 
and zero infections from the 337 PlCCs inserted by respiratory therapist (0.0%). 






■ RRTs 







Conclusions: Respiratory therapists that receive specialized training, equal to the train- 
ini! a a'gistered nurse, can safely insert a PICC without increasing the risk for infection. 





Misty Prater RTS . Christa Pruitt RTS. Timothy B. Op't Holt. Ed.D.. R.R.T. 
University of South Alabama. Mobile. Alabama 

Background: Inadvertent extubations can be associated with life-threat- 
ening consequences. Therefore, evaluation and prevention of unplanned 
extubations are major concerns for healthcare professionals. The purpose 
of this study was to identify criteria for patients at high-risk of 
inadvertent extubation by evaluating the occurrence of and factors related 
to inadvertent extubation. Methods: All mechanically ventilated patients 
at the University of South Alabama Medical Center (USAMC) between 
December 13. 2000 and January 13. 2002 were included in this study. 
Details of each inadvertent extubation were obtained from an incident 
report, chart review, and interviews with the respiratory therapists 
involved. Staffing, time, and location of each incident were also 
recorded. After reviewing the data, each unplanned extubation was 
placed in a category based on cause and also ranked according to severity 
of outcome. Results: A total of 42 inadvertent extubations occurred (7.8 
inadvertent extubations/ 1000 ventilator days). The causes of inadvertent 
extubations were as follows: failure to extubale or properly sedate {2\9c). 
insecure tape job ( l2*/r ). inadequate sedation ( U)'//^). accidental (29'^). 
negligence { KKr ). and uniimely extubation ( 10''.f ). The severity of 
outcome of the unplanned extubations were mild (n=22. 557r). moderate 
(n=6, 14*^), and severe (n=13, 31%). Conclusions: Our study indicates 
that 7 1 % of inadvertent extubations were preventable. The majority of 
incidents could have been prevented with either adequate sedation or 
timely extubation. Education of healthcare professionals on adequate 
sedation, timely extubation. and paticnl/tubc manipulation may minimize 
the occurrence of inadvertent cxiuhalions. 


Design of Medical Vacuum System for lise in Space 

Jimmy Wu BS. Terrell M. Guess. Victor Hurst IV PhD. George Beck BA. RRT 
Wyle Laboratories Life Sciences Systems & Services. Houston, T.X 


The International Space Station (ISS) Medical Operations Requirements Document 
(JSC SSP 50260) states there must be a means to pro\ide ad\anced life support 
( ALS) aboard ISS. Fundamental to ALS is the requirement for medical vacuum 
capabilities that allow for airway management, cavity drainage, and biohazardous 
waste management. Most terrestrial medical vacuum systems use gravity to 
separate air and fluid. This is not an option in space; therefore an alternative 
method of air-fluid separation must be used. Furthermore, a means to filter the vac- 
uumed air stream must be implemented to remove airborne microorganisms and 
aerosolized particulates so they do not pose an additional contamination hazard to 
the ISS environment. 


A trade study was conducted to evaluate air-fluid separation technologies used in 
lerreslnal medical \ acuum systems. In addition, technologies used on the space 
shuttle and ISS that perform air-fluid separation (toilet, shower, wet/dry vacuum, 
condensation collector) were investigated. Tliese technologies were evaluated 
based on sc\cral criteria including performance, mass, \oluiiic. power rcquircnicnl. 
and cost. Se\cial dcsiLin conccpis ucrc developed ih.ii \M>uld coiuerl these existing 
vacuum sysiem lecliiiologies into a space medical \aciiuni s\s(cm (SM\ St. All 
these concepts involved use of a bactenal/viral air filter and a closed suction 
catheter. A parallel trade study of these devices was conducted to select the best 
commcrcial-ofl-ihe-shelf (COTS I filler and catheter. 


The ISS wet/dry vacuum (WDV) cleaner assembly met the most requirements but 
still needed modifications for use in medical contingencies. An adapiaiitm design 
was selected that required no direct modification to the ISS WDV. Instead, the 
SMVS consists of attachments that accessorize the ISS WDV enabling medical 
\ acuum use. All biohazardous waste is separated and contained within SMVS. 
external to ihc WDV The COTS bacterial/viral air filter isolates airborne microor- 
ganisms and paiiiciilaies. while the closed suction catheter serves as the patient 
iniertace and added pmicciion for the crew care provider. 


Deploying a medical vacuum system for use in space will serve to enhance ALS 
aboard ISS. SMVS represents a combination of COTS and currently flown NASA 
devices to provide augmented critical care capability in space. 
This work was supported under contract to NASA. NAS9-y7tKJ5. 



RESPIRATOR^- Care • September 2002 Vol 47 No 9 

SA^URl)\^, OcroHi R 5. 

M)-2:25 I'M (kdOMs 2(1 

FLOW RATKS Tom Nhilimwski. RCP. RRT. HAARC . James Lambcrli MD. 
Im)\a lairfav Hospital, halls Church. VA. BACKGROl'ND: A new huniichficr 
iVapolhcnn'^M dcsiun allows tor the dcli\cr\ ot heated, huinidit'ied oxygen ul 
higher levels of oxygen liter tlow. We sought to detemiine the actual inspired oxy- 
gen concentrations being delivered \ia the Vapothenn" cannula at higher- 
than-a\crage tlow rates to .1 test uukIcI .11 \ar\ing tidal \oluiiies .iiul icspii.itory 
rates, MKTHOl): ,-\ miHlil'ied, dual chamhered lest lung l\ eiit,\id ' Irainnig 
Test LungI connected to an adult C'PR manikin and incch.mical \entilatt)r 
simulated a spontaneous breathing patient. When the \entilator cycled, side one of 
the test lung pressuri/ed, simulating a spontaneous breath \ia the manikin, A 
Vapotherm adult e.innula v\ as pl.ieed into the nares ot" the model and oxygen How 
adjusted accordingly , Model ciMlducling deadspace \olume (nasopharynx, trachea, 
conducting ain\a\si was similar in si/e and \olume to actual adult deadspace, 
N'entibtor Settings (Test lung compliance l),0-^ L/cm H:C)) 
Frequency I hpni I I \t mill ranges | Insp. linu' ri- | VclK/minl 




2(H). ,'MI(I. 4(10. .'sdd 

.100, 4(K1, SOO, hOd 

400, .SOO. 60(1, 700 


S,0- 20,(1 

'),o- is,o 


Respiratorv Kate 

VI (mL) 

Obserxed oxygen concentration C/f ) at: I 



25 LPM 





























































0\> iien coiiceiunilion as measured in the deadspace w as consistently > 7( )'-i . reiiiudless 
of tidal \olumeor\entilator\ pattern. Higher tlow rates resulted in higher inspired oxy- 
gen concentrdlions in some circumstances. CONCLUSIONS: Higher ihim typical 
fiou rales \ ia nasal ciinnula result in clinically significant ele\ ations in oxygen concen- 
tration dunng a vanety ot \enlilalor\ rates, inspiratory Howmtes. and lidal \olunics. 
Higher Hows ol fiasal ox\gcn pro\ide an alicnKitive tecliniquc to simple or non- 
rehreathing masks tor adminisieniig higher inspired i*\\gen c(^>ncenlrations. 


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Respirator^' Care • September 2002 Vol 47 No 9 


Improve Your Disease Management Program 
• Help Your Patients Help Themselves • 

Hciltlt Ti|n 

Helping Your Child BieaUie Easier 

HMlth Tips 

Living with Asthma 

Exercising Safely with COPD 

Smoking "I.Q:' 

Quality healthcare is just one key to disease management 
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the two together and you help your patients improve their 
quality of life. You can do it with the AARC's Health Tips 
and Health IQ Quizzes. These peer-reviewed information 
flyers come in convenient pads of 50 tear off sheets. 

• Helping Your Child Breathe Easier • ITEM R23-AQ 

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• Living with Asthma • ITEM R32-AQ 

• The Process of Quitting Smoking • ITEM R33-AQ 

• Exercising Safely with COPD • ITEM R35-AQ 

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• Lessening the Effects of Sleep Apnea • ITEM R40-AQ 

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SaTI'RIV\>. 0(T()BI:r 5. 3:00-4:55 PM (Rooms 18-19) 


Ruhcn D Rcsircpo. MD. RRT. Doug Curilcnhirc. MS. RRT Dcpl. of 
C;inJiopulni(tnar\ Care Sciences. Georgia Slate rni\ersit\ , Allania. CiA. 
BACKGROUND: Web CT is one ot ihe leading providers of u eh based lech- 
noIog\ available lo tacull\ lo enhance their inslruclion. It lacilitates the 
creation of sophisticated World W ide W eb-based educational environments. In 
a similar sludv conducted in the year 2{KM), 50''; -75'^ ol the students v\ ere sat- 
isfied w ilh the use ol' WebCT. However. onl> 1 2 siudenls (4.VI ) reported lo 
have interest in taking an onhne course based on thai e\(>erience. The purpose 
of the study was to evaluate student acceptance ol Wcb-enhanced courses in a 
hu"ger group ot" students throughout the last three sears Ywo specific questions 
were investigated: I ) How satisfied were students u uh the use o\ lecture plus 
web-based technolog> to deliver the course .' and 2) Would students take a 
course on-line based on their cxpenence with these courses'.'. METHODS: 
Two coup.cs taught b> the same instructor were evaluated. A tola! of I 1 5 stu- 
dents enrolled in the program between 2(MX) and 2(H)2 were surveyed at the 
completion of each w cb-cnhanccd course. A questionnaire produced for a 
Computer Science Department at the University of British Columbia was used 
to answer the research questions. Descriptive statistics were calculated. 
RESULTS: A total of 1 1 5 students did access the course material through Web 
CT. The total number o\ hits reponed to the W eb sites w as .^SS9. w ith a mean 
of 48. and a range of 1 - 16 1 Percentages are reported as follow s; 

Ho» salivficd were \iiu with Ihe u^eol"WehCT in l;iking RTcourM-s' | 

Not al all 

N\)t >alistied 



Ver\ salistied 






V\'i>u!d Mm I.ikc an un-line cour>e ba>ed on \ our experience with WehCT' | 





CONCLUSIONS: There was a much higher degree of satisfaction with the 
WebCT courses than previouslv reponed |92'^( vs. 75*^^). Computer 
proficiency along with a change in the learning style and more exposure to 
internet-based education may explain vvh\ 66 out of the 115 students answered 
they would take an on-line course based on their experience with these two 
web-enhanced respirator)' courses. 



Doug t.'r.irdeiih ire. MS. KR I Dcpl til Cardiopulmonary Care Sciences. Georgia 
State Universit) (GSU). Atlanta. GA. 

BACKGROUND: Computer technologies probably represent one of the most 
innovative strategies to facilitate effective and efficient teaching and learning. 
Web CT is one of the leading providers of web-based teclinokigy thai allows 
faculty to enhance their instmction via the creation of World Wide Web-based 
educational environments. Student participation is typically measured by the 
number o\' v isiis or "hits" to the web site and its dillerenl content areas. There 
is minimal information about the use of Web-enhanced respiratory courses m 
the traditional rcspiralorv programs with campus based students, hurthennore. 
Ihe etfccts on student performance have not yet been documented. PURPOSE: 
fhe purpose of the siud> was lo correlate student participation and performance 
of five groups of students who have enrolled in Web-enhanced respiratory care 
courses at GSU. METHODS: RT Mm (Cardiopulmonarv Physiology), a 
three-hour credit course ottered during Ihe I'lrsi semester ol the junior \ear. and 
RT 4(181 (Neonatal Respiratory Caret, a three-hour credit course offered during 
the last semester of the senior year were evaluated. A total ol SI students, with 
no prior WebCT experience participated. The number ot "hits " or visits to the 
Web site and course grade were recorded lor each student and I urthcr compared 
for boih courses. Statistics were calculated using SPSS version 10. Chicago. IL. 
RESULTS: Eighty one students did access the course material through Web 
CT and lecture. 37 students for RT 3005 and 44 students for RT 4081. The 
a\ erage number o\' hits for both courses w as 48+29 and the course grade aver- 
age tor all groups was H69c±6'7c . 
There was a low association of cor- 
relation as described using the Davis 
conventions I r=. 24. p<().05). CON- 
CLUSION: Although the 
correlation between number of hits 
and grade average was low. there 
was a significant difference in 
student performance as the student 
increased participation reOected in 
the number of v isiis to the web site. 
There was not a significant difference in a student pcrtbrmance when this respi- 
ratory course was offered both in a traditional setting and on-line. Factors such 
as computer proficiency and motivation may considerably change student 
acceptance and performance. OF-02-01 2 


Ruben D Restrepo. MD. RRT. Doug Gardenhire. MS. RRT. Dept. of Cardiopulmonary 

Care Sciences, Georgia State University. Atlanta. GA 
B.XCKGROUND: Technolog> -enhanced education is becoming an impvirtant p:in of 
pnifessional education. Web-based cours,es serve the needs of both traditional and non- 
traditional students b\ expanding their studv options and allow ing llexibility to set their 
ow n pace of learning. The traditional student ptipulation represents only 25'^r ot campus 
enrollment (Van Dusen. 19981. making online education a ver\ attractive alternative to 
meeting the needs of the changing student population. Nevertheless, conversion of cur- 
riculum fn)m a traditional classroom env ironment to the Internet can be a challenging 
task. Though technologv ma\ add appeal to online courses, then: is a grow ing interest in 
and concern for a.ssessing student" s learning with the use of this new methtxl for deliver- 
ing education in the traditional cainpus-ba.sed student ptipulation. Web CT is one of the 
leading pn)v iders of web-based technology that allow s faculty to enhance their instruc- 
tion via the creation of World Wide Web-based educational environments. PURPOSE: 
Despite the recent utilization of online education in the respiratorv field, the effects of its 
use in lecture-based respiratorv programs and student pert'omiance has not yet been dtx.- 
umented. The purptise of this stud> was to evaluate pertonnance of a small group of stu- 
dents w ho V olunteercd to take the Neonatal Respiratory Carc course ( RT 408 1 ) on-line 
with the students who use lecture plus web-based technology to cover the material. 
METHODS: RT4081 is a three-hour credit course offered during the last semester of 
the senior year. All students (n= 19) had access to the course materials on WebCT H<tw- 
ever, five student.s wert given the option to take the course completely online. The num- 
ber of "hiLs" or V isits to the \V'eb site and course grade were recorded tor each student 
and compared on both groups. Descriptive statistics were calculated RESl'LTS: 
Twelve students did access the course material through Web CT and lecture. (Ive 
students look the course online, and two students preferred lecture onlv The average 
numberof hits for the online group was 54 ±25 versus 36 ± 14 hits tor the WebCT plus 
lecture group. The course grade average was Sl'^ ± 3.7'^r for the online gn)up versus 
81*^ +3.6*^ for the WebCT plus lecture group (p=0.46). Even though, the computer 
proficiency for the WebCT plus lecture group was reported to be higher after taking the 
course, thert was not a significant difference on computer proficiency between groups 
both either before or after taking the course {p=0. 22). CONCLUSIONS: Despite the 

_^-~ — limited number of students, there was no 

difference in student pertormance when 
this respiratory course was offered both in 
a traditional selling and on-line. Computer 
proficiency and motivation did not 
imprt)ve scores for those who volunteered 
to take the course online, A larger group 
of students may be necessar\ to correlate 
number of hits and student pcrtbrmance. 

OF-02-01 1 



Ar/u An. MS. CRT. CPFT . Joseph L.Rau. Ph.D. RRT. Lynda Thomas Goodfellow . 
Ed.D. RRT. Georgia State University. Department of Cardiopulmonary Care Sci- 
ences. Atlanta. GA. 

Introduction: Prcxedures for measuring teaching effectiveness and quality of 
instruction vary with different respiratory therap> schools. Because of the high cor- 
relation between quality of instruction and high student achievement, it is 
understandable that leaching effectiveness of clinical instmctors needs to be 
carefully monitored. TTierefore. many colleges and universities have adopted the use 
of student ratings of instruction as one and often the most infiuential measure of 
instructional effectiveness'. The purpose of ihis study was to investigate 
detemiinants of leaching method and elfcctiveness on qualit> of instruction in the 
clinical education of respiratory therapy- 
Method: A survey insuument has been developed hv the Department of Cardiopul- 
monan. Care Sciences at Georgia State University in order to have student evalua- 
tion of clinical practice. During the 4-year period 1^)W- 2002. a total of 21 1 
student's evaluation of clinical education were collected and used in this stud> . To 
address the research question, correlation between each leaching nieihcxl and qual- 
ity of instruction was analyzed using Stepwise Muhiple Regression Analysis, at a 
0.05 level of significance. 

Results: Regression analysis showed that there is positive correlation among 
aspects of leaching and quality of instruction. Integrating of theory to practice, 
allowing adequate lime for priK'edure. clantying of questions, motivating of 
students and demonstrating enthusiasm significantly (p<0.05) impacted quality ol 
instruction more than other variables. Together, these variables explained 84*:^ ot 
the variance in quality of instruction. Other variables of leaching methods, like pro- 
viding feedback, minimizing anxiety, goixl organization, and providing physician 
input did not significantly increase the squared multiple correlation (R^) of the 
model using stepwise multiple regression. 

Conclusion: Teaching effectiveness in clinical education is impt)nant for 
respiratorv therapy administrators, clinical instructors and preceptors in making 
infomied decisions on the apprt>prialc use of student evaluation in clinical 
education. Respiratorv therapy school administrators and clinical instaiciors can use 
the individual items as a list of prioritized crucial elements that should he focused 
on in the training of respiratorv therapy students in the clinical settings. 
1. D'.Appolonia. S.. Abrami. P. C. Navigating siudent ratings of 

instruction. Amencan Psvchojogist. 1997: 52 ( 1 1): 1 198. 


Respiratory Care • September 2002 Vol 47 No 9 


Saturimy. October 5. 3:00-4:55 pm (Rooms 18-19) 




Arau Art. M.S.. CRT . Lynda Thomas CiiHuHcllow . Hd.D. RRT, Alan Biggs M.A.. 
RRT. Josepli L. Rau. Ph.D. RRT. flcoijiia Sla(L- IJiiivei-sity, Department of Cardiopul 
monan Care Sciences. .Mkuita. G,A.. Anieriean Hospital. Respiratory Therapy 
Depanniem. Istanbul. Turke\ 

Intniduction: There rs no torniaily ieeoj:ni/ed piDtessioii ot respiratory care in 
Turkey . Currently, respirators care services are provided by a rni.vture of professional 
people such as physicians, physical therapists, and nuiNes. The purpose of tliis study 
\\ as to in\ estii:ate w hat Turkish medical professK>nals w ho perform respiratory care 
procedures think about ha\ mil: an American onenled respiratory therap\' education 
pio>;rain in Turkey. 

MethiHls: A research itnil in the fomi of a suney insti-umenl v\ as de\ eloped to 
address the research question in this stud\ The survey conlained 17 items that 
attempted to descnbe p;inicip;inl's thinkiiii; about a respiralorv care education 
program in Turkey. A four-day respiratory theraps education prograiri was prepared 
by faculty from the Department of Caidiopulmonary Care Sciences at Georgia State 
L'nisersity. al the request of Ktx" UniveiNity m lst;inbul. Turkey. A total of 88 partici- 
pants including nurses .uid physical therapists from all p;u1s of Turkey were surveyed 
at the end of this lour-day respiratory therapy education program. To address the 
resciirch question, frequency tables were generated for btith physical therapists and 
nurses, using SPSS for Windows. 

Re.sults: 41V{ of participants in this study included physiotherapists, and the remain- 
der oi the ^^'y'r were nurses. All physical therapists and 4 1 .5'/ of nurses see 
respirator},- therapy as a growing profession in Turkev . They all think that olTering an 
Amencan onented respirator) therapy education program is needed. Both physical 
therapists ( 82.9'^ ) and nurses ( 74.5'/f ) would like to have a respiratory therapy degree 
program. 58. 5^^ of physiotherapists iind 76.6'r of nurses believe that they will get a 
better posititin after their completion of such a pn>gram. 

ConcliLsion: .A comprehensive program of respiratory therapy education can create a 
respirator)' therapy profession in Turkey and c;ui meet the needs of both the people 
deli\ering this care and the patients m the hospitals who need this type of care. Turkish 
medical professionals are aw lire of ihis growing need hir leaders in the respiratory care 
profession in Turkey and indicate that they are ready to be trained through a fomial 

program of respiratory therans such as what is in the United States. „. 

' ' ' ■' '' OF-02-020 

TECHNOLOGY Douglas E. Masini . Ed D. RPFT. RRT. Pennalal- 
Pcdiatnc Respiratory Care Speaalist, Assislani Professor. East 
Tennessee Stale University. 1000 W E Street, Eltzabethton, TN 
3764.^ W: (423) 547-4917 nxasini » elsti cdu 

I investigated the presence, utility, and emergence of tacit louwledge 
in 9 participants who used assistive-augmemative technologj' 
(mechanical venulalors. ult-in-spacc wheelchairs, sipy-and-puff 
systems, speaking valves, and complex environmental control 
systems) ! conducted phenomenologic mterviews. audio-taping, and 
transcribing the interview with the written consent of the pamcipants 
and IRB approval Sixteen highly trained expert respuatory care 
practitioners (RCP) and 15 students cntiqued the fmal product of the 
interviews and answered a 25-question survey instrument. Non- 
parametnc statistical processes were chosen to conduct tnferentiaJ 
hypotheses testing (alpha (a) level of 05) Wilco.xon-Mann 
Whitney U tests and iCruskai-Wallis' One-Way ANOVA were 
utilized for questions 1-10. and a 2 x R (R = 3,4) contingency table 
and Fisher's Exact Chi-Square were used for questions 1 1-25 The 
responses lo survey questions showed no statistically significant 
differences or interactions for the variables gender, e.xpenise, and 
service ip < 0017) Quahtalive analysis found discemable heunstics 
and ideation that was indicative of implicitly learned taat knowledge 
in partiapants; the utility of tacit knowledge emerged dunng direct 
observation or when participant's engaged m analogy . allegory, 
storytelling, and metaphor. Study partiapants used introspeculalion, 
a learning style framed by reflection and introspecuon on the validity 
of one's own knowledge and the value of what is learned both from 
expenence and in the classroom. The introspeculauve e.xammed the 
presence and utihty of taat knowledge in their decision-making, and 
questioned the veracity of sources and resources that gmded them m 
practice, m teaching, and on their path of life. 


Evaluation of an Educational Pni^ram De.signed tu 
Assess Knowledge of Ventilator Waveforms 

Jcnni L. Raake. MBA. RRT . Scott Pettinichi. MEd. RRT. Jerry Edens. BS. RRT 
Children's Hospital Medical Center. Cincinnati. OH 

Introduction: Ventilator wavefomis have become a p;u1 of the patient ventilator a-ssess- 
mem. L'nderstanding and interpreting wavefonns have been obstacles to incorporating 
waveforms into patient care assessments. We developed an educahon program to assess 
know ledge and increase understanding of wavefomis. 

Methods: .A vnluntarv. initial survey was sent out by intra-hospital email toallchnical 
ihciapisis containing demographic infomiation and ten pretest questions consisting of 
common vvav efomis, \n in-serv ice was performed on two separate occasions followed 
bv a posl-tesl containing the same wavefomis. Responses given to the tests were 
tabulated and average scores were reported. 

Results: Mean pretest scores showed 6.7 correct, while mean posttest .scores were 9.7 
correct. Mean responses were broken down based on credentials, years of experience, 
and education, and are rep<irted in the tabic below 


Pretest Score 

Posttest Score 








Technical Degree 












^'ears Experience 



















Conclusions: Based on the intoniiatioii ubiaincd through our survey, cliniciil Ihcrapi.sis 
in our tacihly were able to ilenionsirate an iniprtnemem in their knowledge of venlilator 
waveloniis alter education waspnuidod. __ _„ -__ 


Amy Hildenhrantl & Jill Sa\ane. Indiana L'ni\L'rsil> ktspiraIor> Tht'rap> Students. 
Linda Van SecHlt-r, KdD. RRT. Associate Pnilessor, Indiana L niversil> 

PURPOSE We intended to discover why recent respirator) therap) prognini graduates in the 
slate ol Indiana have or have not taken the entr^-level examination lELE). the v^ritten registry 
examination (WRE). and the clinical simulation examination (CSE). BACKGROUND A 
trend exists in graduates not taking board examinations. The ELE has been shown as an effec- 
tive way to represent the graduates' skills and knowledge- However, some studies have shown 
ihcWREi iohLi\c L|Licsiniiiahle \alidii\- .Also, the WRE now cn\ers73'^i of items at the analysis 
le\cl and nia\ ncci] ic-c\aki>iUoii to see if an additmnal lest, such as the CSE. is needed to 
denionsii.iic prohlciii-soK ing jhihi\ , METHODS In this descnplive study, a 1 5-item survey 
was sent lo graduates ol 7 o\ the S Indiana respirator) therap> paigrams. Graduates had approx- 
imately one month to return the survev . Graduates were asked tti rank the importance of each 
response, and they had the opponunit> to till in an open-ended response as well. A pilot survey 
was conducted m a kirge mid-western hospital lo ensun: reliability using the lesi-rctest methtxl. 
RESULTS Tlietesi-relest reliability of the survey insirumeni a\ eraged I) •^.'i One hundred and 
sixly-nirie sur\cvs were sent out lo the avenl graduates. Sc\cnl\ -one usable sunevs were 
relumed repivscnlin-j A2' • o\ ihuse sui'\e\cd. One hundred jxtcciU ol rcsfh(inlcnls uxik the 
El.h. 7S.S7',, i.H)k liic W Ki- ,m^\ CSh. The m.un rcason tor lakmg the 111:. W Rh. and CSH 
u as for [XTsonal .ichicv emcnl The second re;ison was pay increase. Those who did not lake 
the WRE and CSI: did luu lake il because of the costs and lack of time. Only ilia'e rx's|X)ndents 
did not plan m lake llic WRi: a\k\ CSE 

ResiMHuk'nts' Reasons tor lakin^ Board I Aanunations 







( [X'lccntages.l 





EI.E n=7l 

-not inipiirtant 


ly 12 




-snnievvhal iinfiort.inl 

I7 6.'i 





-verv ini[xinatil 


61), 12 






15 15 





-soiiicw hal iiii( 



5 97 



-verv important 



92 54 




-not iinponanl 



1 52 


33,85 impiin.ini 

2(1 (Kl 





-vci-\ ini|ion.iiil 






CONCLUSIONS We conclude that reccni graduates lake ihc bo.ird evaminatinns for [vrNoiial 
achicvenicni. possible pay increase, and in ilic case d the hi .E. ihc laci that ilic sraii- leiiuiics n 
Only three ivspondents answei^ed that Ihey ha\e nt)i taken or do not plan lo lake the WRE and 
CSE. llierefoR:. we could nol draw any solid conclusions as to why therapisLs are nol taking 
these boaal examinations. Many graduates responded saying that earning ihe RRT credential 
will nol cause a pay incnj.ise. Since the sunevs were aiioininoiis. we wca' unable to detemiine 
how iumTcs|HiiKlcts Icel. NV'c suggest ili.ii .i [laiinnal sur\c\ Iv i^ondiicicd on this subject, with 
special care given looblain ivs|ionscs Irorn ihosc who tin not inieiulin i.ike 
the boiird examinations, OF-02-025 



Saturday. October 5, 3:00^:55 pm (Rooms 18-19) 

APY'. Lolic P-at/u^ihl. BS. RRT. Lucy Kcslcr. RRT. MBA. FAARC. Juiiics K. Slollcr. MD. MS, 
I-AARC, The Cleveland Clinic I-oundation. ClevelaiKl Ohio. 

Introduction: In the context thai pniitvol-dirvcted care unplenicnicd by [vspjralory iherapisls 
has been shown to offer more appropriate a-spiratory caa* than usual physic lan-Jirvcted care, we 
wished to examine the caliber and qu.uUily of a'spiraiory care training olfered to iiKdical 
studentN, Tlie hypothesis is that sparse initial exposure to a'spiraior> therapy may contnbute to 
later inattention and lack of respiratory therapy expertise amony physicians. To assess the 
amount of attention given to instructing medical students reganling respiratory ciire. we assessed 
the respiratory care content of tcxibixiks assigned in meilical schixtl cumcula ot three Ohio med- 
ical sch(X)ls. 

Methods: Tcxtbixiks were identified by contacting the cixirdinator/dirccloi ot curriculum devel 
opmeiit at three Ohio medical scho^ils, BiK>ks were those used m conjunction with first and sec- 
ond yciir medical student instmction regarding pulmonar) physiology itnd pathophysiology. The 
lextbixiks that were idcntillcd by the curriculum c(x>rdinators were: 
I Pulmonar.' Physiology. Michael A. Gnppi. M.D. with eleven additional contributors, J. B 
Lippincott Conipan;. Philadelphia. 308 page*.. 1995. 

2- Respiratory Physiology, The Essentials. John B. West. M.D,, Lippincott. Williams iuid 
Wilkins. Philadelphia. 142 pages 16"^ edition. 2000). 

.V Pulmonary Pathophysiology: The Essentials, John B. West. M.D , Williams and Wilkins. Bal- 
timore. 166 pages 15"" edition. 1995). 

Specific respiratory therap\ topics regarded diagnostic Issues ( including use of pulmonary func- 
tion testing lie,, their pcrtormance and signiftcancei), pulse oximetry, arterial blood gases, respi- 
ratory failure, and therapeutic issues (including use of supplemental oxygen, mechanical ventila- 
uon. and brx.>nchodilator>). 

Results: Table I prtsenLsthe amount of space (rounded to the nearest page) allocated to 
discussing respiratory therapy issues in these textbooks Our survey suggested that inhaled medi- 
cation devices, hypennflation techniques, secreuon clearance techniques, and use ol artificial air- 
ways were not discussed in these textbooks. 

Table I. Review of Textboolu 

Schixil Physiology 


Pulmonary Arterial Oxygen 
Function BUxxl Gases 

Ventilators Bronchtv 

I 5 pages 

2 page 

1 4 pages 6 pages 2 pages 

5 pages I page 

2 10 chapters 

1 page 

1 2 pages 2 pages 

4 pages 

.' 5 pages 

I page 

2 pages 

4 pages 

Conclasioas: Recognizing the limited sample of textbooks examined, our data suggest relative 
inattention to respiratory therapy issues in first and second-year medical schixil curricula While 
the current survey did not address respiratory therapy education dunng medical students" later 
clinical aitations. the sparse fomial textbook coverage suggests that physicians receive respira- 
tory therapy education m an "on the job" context. The opp(.)rtunities to enhance respiratory ther- 
apy education among physicians warrants re-examination of how and when to best educate 
physicians- in- training regarding respiratory therapy. OF-02-030 

liiiuiths R Myers BS. RRT . Thomas Kallstrom, RRT. FAARC & the Mullicenler lndiK)r Ijivi- 
a)nmcni Study Gn)up lor the American Respiratory Care I-oundation. American As.socialion for 
Respiratory Care & the Environmental Protection Agencies Indoor Division. 
Dallas. Tx & WashingH)n D.C. 

Ininxluclion. The home envimnment is one of the crucial components of any comprehensive 
asthma management program. The ultimate goal in envmininental control is eradicatmii ol the 
oflending trigger sourec. or at the very least a reduction in exjxisure" to irritants. The pnnuiry 
objective of this pilot project was to identify and attempt to reduce iiidtKirenvinmmenial triggers 
(by 25^r ) through a respiratory therapy-driven intervenlion. Melhixls Mullicenler study of chil- 
dren aged 1-18 \can-aLiiiiitlcd lolhe hospital or visaing llieenicrj!eric\ tlcpartment (ED) for an 
asthma exacerbation wcfcclij:ihle liir the study Study centers wcic K^aicd in 3 regions of the 
LI S . the South. Malwest ami Northwest CeiileTS were located in mctrn| inner-city neigh- 
borhtxxls. Study participants had a history of astlima or reactive airways disease. Patients and/or 
their parents were questioned re-garding the child's exposure to indtxjr asthma triggers such as 
dust mites, pcsis. [vis, molds, etc... . After completing aquestiunnaire. an intervention was 
miplcmcTitcd b\ respiratory therapists to educate and suggest mechanisms to reduce or eliminate 
tnggers L![X)n disLliarge. families were contacted initially at 7- 10 days alter discharge and again 
at 2 and 4 months to assess for behaviour changes that either reduced tir eliminated indix)r 
a.sthma triggers. Results. A multicenter educational intervention with 437 study pariicipants. 
The majonty of patienLs were black males (61.1'^ iind 58. 1 '/r respectively). The table below 
represents uveral I percentages t if (miential tnggers (by category) re'|x>ned to be present in study 
piirtic I pants' homes. A specific bie;ikdown found the following triggers present in study pariici- 
pants' homes (overall percentages). Dust mites exposure as a potential tngger was the most 
prevalent source overall (stuffed animal s=6S7f. absence of dust-pr«)f casings =52%. bednxim 
or TV nxim carpeting =709J^) Almosi4l*'f ol children in this study were exposed to second- 
hand cigarette smoke. In the two Soutliem study sites, over 50Vr o\ the study participants were 
exposed to second-hand smoke. The most pre'vaicnt pet tngger re"ptirted in the home was a lam- 
liy dog (23'v^ overall). The two most prevalent pests sources as tnggers were mice and 
cockroaches ( 10*7^ and 9*7r ). However in the two Southem study sites, the presence of 
cockroaches were more prevalent than the overall study average (27'/( ). Unemptied refrigerator 
drip pans 121%) were the most frequently reported potential tngger sourec tor molds and 
mildews. For the category of fumes, a natural gas stove was the most frequently reported source 
as a potential tngger (53*7^ ), Pt)st intervention contact made by respiratory herapisLs fouml .i 
decrease in study rentention with e;ich phone call (6S'a . 4yVf . 47%). 


OVL-Rill PL-acru.igc 

TriLji^cr Cjlcyorv 

(Xerall PeacnlaiiL" 

Sucond-h.inJ Smoke 

23 3'/; 





Molds & MilJcw 

25 1'.; 

DusI Miles 




Conclusions. For the 4-nionlh duration of this multicenter. pilot study by rcspinitory Ihenipisl, 
,38% ol the childni;n had home inter\'entions or behavior modifications that led to the reduced 
potential orcompleteeliminationot polenlial indoortnggen^ota-slhma f-.^ /^p r,^. 

EDUCATION COMPONENTS. Helen M. Sorenson. MA. RRT. The Univer- 
sity of Texas Health Science Center at San Antonio. San Antonio, TX. 
Background: Respiratory therapists (RTs) are increasingly being called upon 
to care for older patients in a variety of settings. While some respirator)' care 
programs offer gerontology courses, there is currently no mandate to include 
geriatrics in respiratory care educational programs. The purpose of this study 
was to determine what aspects of geriatric education are perceived to be most 
needed by RTs and respiratory care managers (RCMs). Method: A 
multidimensional survey instrument was developed to measure the perceived 
needs of RTs and RCMs for geriatric education. Demographics collected 
included age. gender, length of employinenl in years and size of community 
where employed. 23 variables, in the form of brief statements were included in 
the survey, using a 5-point Likert scale, to determine which educational compo- 
nents RTs and RCMs considered as being most and least important. The 
surveys were mailed to 400 RCPs in Nebraska, randomly selected from a list of 
1,055 licensed RCPs supplied by the Nebraska State Board of Health. Bureau 
of Examining Boards. I4ll359f ) complete sur\eys were returned. The 
frequency of responses, means and standard deviation were calculated on the 
collected data. The Pearson Correlation coefficient was used to describe the 
relationship between the variables. Results: Knowing how DNR orders relate 
to respiratory care, how aging affects lungs and how to administer palliative 
care ranked highest in the survey. RTs and RCMs ranked fielding questions 
about sex, discussing patient's nutritional needs and counseling patients about 
end-of-life care the lowest. There was a small but statistically significanl (p 
<0.05) correlation between age and understanding cultural norms (r=0. 18) the 
benefits of physical aclivily(r=0. 17) and the importance of patient's 
rights! r=0. 30): between length of employment and knowing baseline body tem- 
perature (r= -.17) and understanding drug pharmacokinetics (r= -.17); and 
between size of community and understanding cultural norms(r=O.I7). Conclu- 
sion: This study pro\ides a foundation for determining what geriatric education 
components are deemed most needed by RTs and RCMs. The data generated 
from this study may be used as a guide for those electing to insert geriatrics into 
the curriculum of their respiratory care programs. 


RRT and David C. Shelledy, PhD, RRT, University of Texas Health Sci- 
ence Center at San Antonio, T.X. 

Background: There is a growing need tor respiratory therapists, but 
there is a decline in enrollment in respiratory therapy education programs. 
Learning why our students chose the profession may enable us to use the 
information to attract future students. Objective: To compare reasons 
cited by students and those cited by respiratory care educators about 
choice of respiratory care as a career. Methods: A survey was adminis- 
tered to four classes of students (n=64| of our baccalaureate respiratory 
care program. Students were asked to list reasons for choosing 
respiratory care. To determine how well these reasons compare with rea- 
sons cited by program directors, the results were compared with a 
previous survey of respiratory care program directors (n=374). 
Participants in the program director surveys were asked to list common 
reasons students give for choosing to enter respiratory care programs. 
Results: Of the reasons cited, three were listed by both students and pro- 
gram directors: (1 ) a desire to help others; (2) family, friend, or self has 
respiratory problems; and (3) employment opportunities. Focusing on the 
opportunity to help others w hen designing recruitment media, displaying 
advertisements about education opportunities where those with 
respiratory illnesses may see them, and emphasi/ing the growing need for 
therapists may attract future applicants to our programs. The reasons stu- 
dents gave that program directors did no! mention (a desire to work in 
health care, stepping stone to other professions) reveal ideas and opportu- 
nities for recruitment activities, as well as letting us know what strategies 
are less effective. Conclusions: Recruitment stiategics should 
emphasi/.e the opportunity to help others in a health care profession thai 
offers excellent employment opportunities. Recruitment presentations 
can target who know someone with respiratory disease, as well as 
provide information about respiratory care as a step toward related health 
professions. OF-02-077 

Respiratory Care • September 2002 Vol 47 No 9 


Saturday. October 5. 3:00^:55 pm (Rooms 18-19) 










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ASSESSMENT EXAM (WSAE) David W. Chan^ . EciD. RRT, Athens 
Technical College, Athens, Georgia. 

Background: Current NBRC RRT written examinations include 20 items in 
Conlcnl .Area II (Ec|uipnient) that are selected "randimily" triini the 
published NBRC written registry e.xam matnx. Ttie purpose of tliis study is 
lo analyze the distribution of exani items in Content Area II of a RRT WS.^E 
and to evaluate how these exam items relate lo clinical practice in a 
southeastern state. Method: Types of equipment that appear in Content 
Area II of Fomi VI RRT WSAE (NBRC. 19991 are grouped into (A) 
"Frequently perf'omied" and (Bl "Seldomly performed" in a typical patient 
c;ire setting. "Frequently performed' is defined as prcxredures tliat iire done 
daily or more than once weekly. "Seldomly performed" is defined as proce- 
dures that are never done or less than once weekly. A typical patient care set- 
ting includes general and critical care settings in a hospital excluding home 
care, neonatal c;ire. and special procedures. On-site sur\'ey of five 
community and regional hospitals in a southeastern state is done to detennine 
the frequency of equipment usage. Results: 

(A) Frequently pertormed 

Anerial line, CPAP, Flutter valve. 
HME. Mist tent. Oxygen system. 
Pulmonary artery catheter. Suctioning 
system. Ultrasonic nebulizer. 

(B) Seldomly performed 

Bronchoscopy. Cardiac monitor. 
Demand O; conserving device. 
Demand valve resuscitation device. 
He/Oi therapy. High-frequency jet 
ventilation. Incubator, PEP, 
Transcutaneous POi monitoring. 
Transtracheal O2 catheter (2 items). 

Conclusions: Eleven of 20 items in Form VI of the RRT WSAE co\ er types 
of equipment that are not used on a regular basis by RCPs in a typical patient 
care setting. Candidates of the RRT written exam should review the types of 
ei|uipment"that :ire common in home care, neonatal care, and special 
prcKcduies. Likewise. RT programs should contmiie to provide students with 
learning expenences in equipment usage in a variety of 
patient care settings. OF-02-080 


Kathv Jones-Boggs Rye . Ed.D.. RRT, 

Lrniversity Arkansas Medical Sciences. Little Rock. AR. 

Background: The attrition rate of students in allied health professions is of concern 
to educators, administrators, and society. Non-persistence represents a waste of 
financial resources, both personal and institutional, and may have negative psycho- 
logical impacts on students as well as their families, friends, and colleagues. Yet. 
there is \er> liiilc research ideniif\ ing what influences the persistence of undergrad- 
uate allied health students based on the theoretical models of undergraduate persis- 
tence. Understanding why some allied health students fail to persist may form the 
basis for effective retention efforts. Moreover, the broader issue of how financial 
aid and net cost affect allied health majors has not been adequately explored. Meth- 
ods: To address this need, a logistic model of allied health professions student 
\\iihin->ear persistence based on the pre\'ious research ot St. John and associates' - 
was advanced and examined in this study using the 1996 National Postsecondary 
Aid Study (NPSAS:9(i). The statistical method selected for analysis in this study 
was logistic regression Results: The results indicated that persistence decisions of 
two-year and four-year allied health professional students were significantly 
affected by five background, one high school achievement, six college experience, 
and three price \anables. However, results indicated that two-year and four-year 
students were not affected in the same way by these \ ariabtes. Discussion: The pri- 
mary focus of the study was to determine the factors that influence u ithin-year per- 
sistence/ withdrawal decisions of two-year and four-year allied health students. In 
an effort to isolate factors that contributed to changes in persistence/withdrawal 
beha\ lor. the effects of student background, aspirations, achievement, college expe- 
rience, and price were examined. Conclusions: Findings of this study suggest se\ - 
eral important obser\ ations related to w ithin-year persistence of allied health 
professional students. Findings indicated a positive influence on within-year 
persistence for \ariables related to: being financially dependent, enrolled as sopho- 
more, a full-time student, and having a father with a college degree. Variables 
associated w ith lowering the persistence rate were: being under the age of 22, hav- 
ing a mother with a college degree, ha\ ing low college entrance exam scores, hav- 
ing a low GPA or no reported GPA, working full-time, and attending a Ibr-profit 
institution. Allied health professional students were sensitive lo price variables 
associated with loan and grant amounts, as well as tuition and fees. 

'Andrieu SC & St. John EP. The influences of prices on graduate student 
persislcncc. Research in Higher Education. 199.1; .«(2):.199-42.S. 
'St. John EP & Starkey J. The influence of costs on persistence by traditional 
college-age students in communitv colleges. Journal of Community College 
Research and Practice. 1994; 18(i);201-21-V OF-02-115 








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Prt'-hospital I se «f Continuous Pwsitivf Airway Preisurt* for ConKesti\ e Heart 
Kailurty Pulmonary Kdema: A Prospective Ireatmenl, Retrospe(.ti\e Control 
Study. DaviJP.i\lLiLi»MdiRRT , Dennis Hustings RRT. Russell K. Miller MD FACEP. 
Susiin Kcciicy MD. Monahan EMT-P. Craig Gray EMT-P. Pavlukuvich. Hastings. 
Miller, and Kecney aa- iissDCiatcd with the Liniversity oCTexas Medical Branch. Galve- 
ston. Texas. Miller. Monahan. ;md Gray are associated with Galveston EMS. 
Background: Acute respiratory failure (ARE) secondary to congestive heart failurc/car- 
diogcnic pulmonar> edema iCHF) is a lilc ihiraiening emergency that accounts for a sig- 
niilcant number of pre-hospital iniubaiionsby EMS personnel. TTiis, in turn, leads to a 
significant number of intensive care admissions and can certainly account for a longer 
length of stay. Full face mxsk and n;Lsal continuous positive airway pressure (CPAP) 
ha\e been used in the hospital setting for many yeiirs. with great success, to avoid intuba- 
tion of patients sulTenng from ARE secondiiry to CHE. EMS providers, however. ha\ e 
not had this option. Therefore our research questions were simple. By providing na.sal 
CPAP as an option to EMS per\onnel can we make an impact on the intubation rate ( in 
the field ) of patients w ith congestive heart failure/pulmon;iry edema? Can we make an 
impact on the intensive care admission rate and length ot stay for patients with 
congestive heart failure/pulmonary edema' Method: We chose to make the study design 
a "prospective ueatmeni. retrospecti\ e contiol" and si;irted using CPAP on September I . 
I yy? and collected data until May .^ I . I WS ( what is considered to be the ""CHE sea.son"t. 
We limited the study to adult patients suffenng from ARE secondar> to CHE/pulmonary 
edema. The control peritxJ was September 1 . 1 996 - May 31.1 997. We set up a system 
that consisted of a Down's flow generator (Vital Signs). CPAP/BiPAP tubing. Briggs 
adaptor rT' piece), corrugated tubing, adjustable PEEP valve (Bird/LDS PEEP Row), 
and a nasal CPAP/BiPAP mask I Heallhdyne), The equipment is kept in a kit that is eas- 
ily carried to the patient. The DEG wlls connected to the 50 PSl outlet of the oxygen tank 
used by EMS. Once the field diagntisis of CHE/pulmonary edema was made the Galve- 
ston EMS (GEMS) personnel would gauge the level of distress. If the distress was signit- 
icanl enough to wammt intubation then nasal CPAP was applied at 10 cm H:0 pressure. 
If relief was not achieved in a few minutes then the level could be increased to 15 cm 
H^O before calling Medical Control for further orders. Also part of the CHF protocol is 
the use of nitroglycenne. furosemide. enalapril. and other measures to decrease the bloixi 
pressure, GEMS then transported the patients via ambulance to the University of Texas 
Medical Branch Emergency Department where supportive care was continued. Results: 
GEMS responded to 54 patients suffenng from ARE secondary to CHE who met cntena 
for intubation. Of those 54. 4 required immediate intubation. Fifty were placed on CPAP. 
and of that fifty, four failed CPAP and required intubation, ICU admission went from 
\W^r to 48^ and the average hospital stay decreased from 14.8 days to 8 days. Conclu- 
sions; CPAP has been shown in the hospital to be an effective altemative to endolracheiil 
intubation for patient.s suffering from ARF secondary lo CHE. By taking this same tech- 
nique into the pre-hospital setting, it has shown to be effective there as well. This, in turn 
has shown to have a significant impact in the rate of ICU admission and length of stay 
for patients suffering from CHF, OF-02-1 25 

.\ ComiiariMitHif'niriT Nasal Cimtinuuus P(»sitivi- Airwa> Pn-Nsuri- Systems. iNCPAPf, 
Knipluycd inaiii/i-i'iim Lung Model Simulating a Ltm Birth \Ni-ighl Frt-malurv .Nitinate: Lau- 

f vpc LvKt \'i<J^. Mclanic Hiekcy'. Tliinjias BlacLson. RKT' ■'. Tmiolhy Cox. RRT'. Thomas H. Shaffer. 
Phr>'. Su/iiniK Touch. MI>V 'Dclawarv Tcuh & Communtty College, Wilni.. I)ti, -Chnsliana Carc 
Health System. Ncwaii. Dfi. 'A.I. dul'uiu Hospital lor Children. Wilm.. OE. *Thc Lung Center. 
Nemours Foundation. Wjim.. l)\l. Thoina-s JetTeiNon Univcpiily. Phil,. PA 

Pliqjosc: The purpose of ihi.s study was lo evaluate the cITeci of thnx different NCPAP systems on 
vciililalory panimelcrs measured in a luny iiKxlcl dc\igned to mimic a premature neonate. 
Background: ("urrenlly, there is renewed iiilcrest in ulili/in^ an undcrwaicr seal, "bubble NCPAP". to 
nnplcmcnt NCPAP in very low birth weight, prenulua- neonates Numerous theones have been pn> 
[x>scd lo acLounl lor ihe improved oulLome^ cxpenentcd b\ neonates treated v^ilh bubble NCPAP, 
Ilierc IS literature to suj^gesi that NCPAP imptenienicd \i.i ihiv system may mimic high trcqucncy 
oscillatory venlilalion. (HFOV) MethofLs: A bench mtxle! was developed using adnve ventilator lo 
power one side of a Michigiin lest lung in order to simulate the spontaneous tidal volumes of a 7(X)- 
grain infant, A 2,5 mm ID endotracheal tube was used lo simulate airway rcsisuncc The lung compli- 
ance was set at t).00 1 Ucm H2O. A "nose" was fashioned around a 15 mm ID adapter lo allow connec- 
tion of nasal prongs to the breathing simulator. A fixed resistance, differential flow scasor was placed 
in line between the "nose" ;ind the endotracheal lube to measure pressure, volume, and flow based 
panimelers during the tnals Positive end expiratory pressure. (PEEPl. was established using an under- 
water seal, a spnng-loaded PEHP valve, and a Bear Cub ventilator in the CPAP mode. Tlic same 
bn;:athing circuit, oxygen blender, flow meter, and nasal prongs were used to e\ alualc bubble CPAP and 
the spring-loaded PEEP valve. A conventional mf:int ventilator circuit was used on the Cub, in conjunc- 
tion with the ventilator's flow nieler and integrated PEEP vaKe. In a separate test with bubble CPAP 
exclusively, the How transducer was replaced with a hot-wire anemometer designed to measure HFOV 
tidal volumes and frequency. The lung simulator mimicked an infant breathing at a respiratory rate of 
40 breaths per minute, tidal volume of 4.1 ml, and minute volume ofO. 166 liters per minute under con- 
inil conditions with no PEEP applied. Simulator settings were held constant for all test condiUons Each 
system was evaluated at 7, 8. 9 and II) LPM of souree gas tlow and NCPAP scl at 5 cm H.^O Ruults: 


M\ ll.I'Mi 

M\ ll.PMl 


M\ ll.PM) 




7 1.1'M 



1) im 

s (,') 

:; 14 


8 LI'M 



1) 17 







1) 16 

ft M 


3 17 

10 I.PM 



1) I5S 


5 S^ 

< <l 

The hol-wire anemomclcr was unable to delect tidal volumes m the Hf-0\ nioniloniig nunJe under 
llowccmditionsof 7. 8. and9LPM When How was increased to 10 LPM. the monitor registered a 5 
H/ high frequency comptinenl hul no detectable tidal volumes Conclusion: Tidal \olume, minute vol- 
ume, and PEEP levels were all intluenced b\ both the gas flow mie pouenng [he NCPAP system as 
well as thctypcofcxpir.itorv \alvc used losuslain PEEP m this mi.>del Both the bubble NCPAP and 
the spnng-loaded NCPAP systems augmented Lida! volume and minute volume, b) as much as 50''f. 
when compared to the control. The Cub NCPAP had no significant effect on simulator tidal volume or 
minute volume. Bubble NCPAP and the spring-loaded NCPAP system exceeded the desired PEEP set- 
ting by as much as 28'7c The measured PEEP increased with increasing flow rate. The Cub pnxluced a 
PEEP level lower than reflected by both the manometer and mean airway pressure* LCD of the venula- 
tor by as much as 36'7r. Measured PEEP decreased with mcreasing flow rate. An HFOV iid;t] volume 
elTect with bubble NCPAP was not measurable in this lung model OF-02-1 33 

CASE SERIES Sreekumar Suhramanian, MD, Austin E. Delacmz. Jr.. 
B.A. RRT. RPFT . Perinatal-Pediatnc Specialist* and Rafaello Goeting. 
CRT, RCP. Departments of Respiratory Therapy and Surgery, David Grant 
U.S. Air Force Medical Center, Travis Air Force Base California, USA 

Purpose: Methemoglobinemia refen> to the oxidation of ferrous (Fe2+) iron 
to ferric (Fe3+) iron within the hemoglobin molecule, which occurs follow- 
ing oxidative stresses. The subsequent impairment in oxygen transport may 
lead to progressive hypoxia and death. Early identification of this complica- 
tion is often confounded by falsely normal diagnostic testing. The purpose 
of this report is to review the etiology, pathophysiology and clinical 
management of this uncommon, but highly dangerous condition. 

Methods: The database of all arterial blood gas analyses at David Grant 
U.S. Air Force Medical Center from |yyS-2(X)l was reviewed to identify all 
patients with elevated methemoglobin (MetHb) levels.5 patients were iden- 
tified with levels >10%. Their charts have been reviewed, with particular 
attention to any predisposing factors, treatment and clinical outcome. 

Results: The mean methemoglobin level was 25% ( noniial 0- 1 .59; ). In our 
series, topical ben«)caine spray was the most common offending agent (4/5 
patients). The reason for benzixaine use were: bronchoscopy and intubation 
1.^ patients), and nasogastric tube placement ( 1 patient). In symptomatic 
patients, the tlireshold for instituting therapy is a level of 20% MetHb, with a 
lower threshold of 1 0% for patients w ith significant cardiac or pulmonary 
hisHiry . ."Xsymptomatic patients generally do not require treatment for 
MetHb level less than 30%. The treatment of choice for acute, severe methe- 
moglobinemia is intravenous I '.i mclhv lenc blue, at a dose of 1 -2 mg/kg. 

Conclusions: Methemoglobinemia is a rare complication encountered by 
various clinicians. Diagnosis requires a high index of suspicion, because 
pulse oximetry often gives near m>rmal readings. Definitive diagnosis 
requires co-oximetry. Prompt treaunent is essential lo optimize outcome. 

Clinical Implications: Early recognition of this condition, and 
administration of methylene blue can be lifesaving in severe cases. 


Delayed Airway Replacement in the Presence of Persistent Cuff I.eak 

Bot) Estctlcr RRT . Dean Holland RRT. Granl O' Kcele M.D. 
Parkland Health and Hospital System Dallas. Texas 

Introduction: Cuff leaks may pn^sent in 10 to 25Vr all patienii with endotracheal or 
tracheoslomy tubes, ' - Possitile solutions have been offered to Ihe various types of 
leaks. * "* We propvise a method providing continuous inflation of the cutY. The device consists of 
a flow meter attached to a variable length of C>: tubing attached to a small-bore 'T' connector. 
The 9t)-degree portion of the connector is then attached lo a seven-fixit length of kink resistant 
O2 tubing open to ariibienl air, A variable length of tubing is connected to the 'T' conncxnor and 
then 10 a male to male I.V. connection attached to the pilot balloon of the ETT. CutTpn^ssureis 
nigulated with O2 flow meter adjustments and set to minimal occluding volume. 

Methods: Our device was attached to a # 8.0 ETT which connected a ventilator set at AC 1 5. 
Vt 720. 1:E 1 :2 and Row 70 Lpm with a Michigan lung (compliance ji6cc/cmH;0). A twenty 
three-gauge needle was used to introduce leaks (holes) into the cuff of the ETT. Tidal volumes 
and intra-cuff pre.ssures wens captured via ventilator display and a pressure transducer respec- 
tively. Data was collected and nscorded as leaks were added to the system. 


Ml study parameters were obtained using b- 15 lpm 02 flow. 













1 S-6fi 

II -4S 


2 -.14 







\ J exhaled 






cc " s 







11).:. II 


S.7-1 1 

1 4-111') 



0-10 1 



0-4 1 

Discussiun: We have successfully employed our device in three unstable patients and 

[X)stponcd airway replacement for as much as three weeks. This presents an impi>niint allema* 

live to emergent reintuhation when presented with loss of cuft integrity. When incorporating 

this design in the clinii-al arena the clinician should rule out other causes of persistent culf leaks 

(i,e.T-L t'lstula. IfrijioMluiii) .-Msool note.cuft pressures measured at thepiKit balloon do not 

reflect actual cuff pressure. Tliis necessitates frequent monitoring of culT with the minimal 

ix;clusive volume technique. 


1 Rashkui MC. Davis T. Acute complications of endotracheal intubation: Relationship to rein- 

tubalion. mute, urgency, and duration. Cheat 89: 165. 1986, 

2- Cmfts SI .. Al/cer A. Mcguire GP. Wong DT. Charles D; A compari-son of pereutaneous and 

operative tracheostomies in intensive care patients. Can J Anaesih 42.115-9. 1995 

3, Ho AMH. Contardi LAH. What to do when an endotracheal tube culT leaks, J Trauma 40:3: 
486-7. 1990 

4, Spmng .1. U-ncf. Anvstlu-siolnay 81:190- 1 . 1994 OF-02-1 45 


Rf.spiratory Care • September 2002 Vol 47 No 9 

SATURDAY'. ()(T()B1-.R 5. 3:()()-4:55 PM (Rooms 20-21 


Jason M!;;;;iiis. US RK 1. [Vmii llolkmd. RRT, Boh Hsicticr. RRT 

Parkl.iiul lk\illh and MoNpiUil Ssslcni. Dallas. Texas. lX-pailnicii( ot Rcspiraton* Cite 

Kackgnmnd: Airway rcsisUincc. spccificalK endotracheal lube (ETT) a'sisiancc. 
plu\s a major role in ihc attenualion orampliuide dunni; Hii;h Ka'queney Oseilla 
[or> Ventilalion (HFOVl. Ii has heen shown ihai with lariicr HITs (KIT > 5 mm 
ID), increases in airxvav resistance sii:nincaTitl> increase displayed proxmial ampli 
tudes. In the neonatal population. \sc ha\eobser\ed small changes (1-2 cmll2t)| in 
proxmial amplitudes that coincide with ad\erse patient e\eMls. [i\ delerminmi: the 
amphlude distal lo the I; IT. we suiitrht to demonstrate win increases in aii\\a\ 
resistance \wih small \- ITs exhit^it such a small etiecl on proximal amplitude val- 
ues Methods: V neoiKital muliiple-halloon kin^ nuKlel was desij^ned lor the pur- 
pose ol this stud>. In order to simulate aKeolar openinj: and closing pressures, the 
nuHJel was submerged m a lO-gallon aquarium. For continuous monitoring ol pres- 
sure changes distal to the ETT. a small pressure line was placed in the model .ind 
then attached to a pa'ssure differential transducer, A slowdlow (.3 liters/nnnutel 
maneuver was performed to construe! a pressuic-\oiume ctir\e on ihe motlel to 
identit) the lower (LIP) and upper iL'IPt inileclion points m order to set an appn> 
priate mean an"wa\ pressure i\I APi. InMectuin points were ed using a com- 
mercial computer program (ST AT A). The LIP was uleinified at 7 h cmH2() and 
the L'lPwasidentiliedal LV4cinH:{). A HH)V > I OOa was attached to tlie model 
with ihe following settings: NLAP l.UniH2(). H/ 10. Itime 'i .V^. Bias How of 2(1 
liters/minute. and a Fi02 of ,21, The Power control was adjusted to achieve desired 
amplitudes starting al 2,'s cmH2() and increasing to t>\ cinH2() in increments ot 
three. Displaxed proximal amplitudes on the ventilator and measureil distal ampli- 
tudes were captured with lour dilYcrent ETTs: 2.0. 2.5. .^.0. and V.'S 

















2.0 Kir 





/ 4 



") 7 





2.5 F.TT 


2 7 







^. 7 


2 7 


"> 7 

3.0 F.TT 














3.5 ETT 














Dt:slal Xmpliuidcs \cmH20) 

Conclu.sion: Our stud\ shows approximately 0- IQ^^i of the desired amplitude 
actually reaches distal to the ETT. The small exchange of pressure amplitude seen 
with ETTs < .^.5 mm ID during HFOV explains why very small changes in 
displayed proximal amplitude occur when increases in airway resistance present. 
We believe that this information is important and should play a role in HFOV 
management of the neonate. Based on the distal amplitude measurements, this 
work indicates that even small changes in proximal amplitude may be clinically 
significant as an e<uly indicator for an obstructed ETT. OF-02-1 55 


AickFra/ierBS.RRT . Kelly Joplin RRT . Mailin Rohrer. BS. RRT. and Terrence 
Couller MD. Q\^\ Health Systems; Springfield, MO. 

InlnHliK'titm: Tlie alveolar recniilment maneuver (ARM) has been pn)ven to be 
.III etteclive procedure thai impiovtsuxvgenaiion in patients with acute respiratory 
distress svndroinc lis .([^[ilkaiinn in [Hisi .i|vi alive c.irdiac patients 1i;ls been lim- 
itcil due to concerns ul coinpiomising i^auliac output as a consequence of high lev- 
els of |v;ik end-expiralory pre.ssure ( PEI'P), Herein, we describe a of alveohir 
recruitment in a |>ost-o|K*nilive cardiac patient whi> tolerated high levels of PEEP 
without causing heinotlvnamic iiistabilitv 

Case Sumnian : A 74 year old lemalc w ith no umlerlying lung disease presented to the 
SlCl' alter a 7 hour suriierv loi a three vessel C'AIKi and a niilral valve replacement. Ini- 
tial venlil.itor seltin-js..t \\' 20loi .i Vi (v^Ol lOml/kg IBW). rale 12. PF.ItP 10. F|()^ 1,0 
resulted in an AlKi^^' PM'J hour, .)l pM 7 27. PaCO^ .^5. PaO:6S, Although 
comlortable with the ARM in ALI/ARDS patients, we were hesitant lo incorptjrate this 
into our open heail ventilator pioiiKol Hius. PITvP was incr\;a.sed to 12 and repeat .AB(i 
(ji 20.'^()houiMioledapHol7 15. PaCO>4^». PaOOO As a consequence of her clinical 
decline, the c.inlioihoracic surgeon adiniiiisieied ^ .inijis of NaHCOi . lold us to "wiLrm 
up"" the 1010 lel venliLiloi, .iikI i.onsiilkd a piiliiioiiologist iliirly minutes alter bicarbon- 
ate administralmn and increasing i'1.1 ,P Iti I :>cm, Ihc .AlUi revealed a couected pM , how- 
ever. PaO^ was32(FiO^ 1.0). The pulmonologist Increased PEEP to 18. Follow-up 
ABC @ 2245 hours revealed a pH 7..M. PaC"():4y, and Pa():.50. After discussing with 
Ihe cardiothoracic surgeon iuid asstiring hemiKlynamic stability, Ihe pulmonologisi 
ordered a recniilment maneuver. Tlie priKcdure began on \K' 20. rate 10. PEEP 20. Lit 
1 : 1 li>r 2 minutes Observing gcxKl patient tolerance, a second recniilmenl maneuver was 
perloniied 15 minutes later, using a PEEP of 25. Finding this maneuver was also 
(olerated well, .i tliird recn.ii[ment maneuver wa.s done with a PEEP of .^0 followed by an 
ABG .V) mmules later, resultini; m a pH 7. .^6, PaCO^ 46. PaO^ 184, The ventilator 
settings at this point were PC 14 for a Vt of 450. rate 15.F|0: LO. PEEP 18. The 
patient's P/F Ratio ct)ntinued to improve and she was on an F|0: .40 with a PaO; of 100 
the next day. Graphing the fir^t eight post-op ABGs as related to Shunt ''k, PEEP, and 




, '1 


^ 11 


4 S 8 7 


aABO^ ARMpciM4»> ABO 

1 — ♦— SPxnst, _»_ PEEP 

~tx- PF'10 1 

P/F Ratio resulted In the following chart: 

Discussion: This case demonstrates that Ihe alveolar recniitmenl maneuver can be safe 

;uid ellectne in seleel posi-opcralivc cardiac patients. Further studies are needed lo iden- 
tifv patients who would most likelv Ix-nefil or be al high nsk for compile. ilions Irom (his 
pnx-edure, \ OF-02-1 47 

Kurt Meyer RRT, Northwestern Community Hospital. Arlington Heights. IL. 

Background , HeOx is an accepted emergency therapy for severe airway 
obstruction. However, closed s\ stems in current use are cumbersome and patients 
are unable to eat. drink or talk. A conventional na.sal cannula cannot supply enough 
flow to prov ide therapeutic levels of HeOx. The Vapotherm humidification device 
can be used to provide up to 40 1pm of warmed humidified HeOx by nasal cannula, 
avoiding man\ of the drawbacks of closed systems. In this pilot study we compared 
closed (non-rebreather mask I and open systems (HeOx by nasal cannula i in eight 
patients presenting to the Emergency Room with acute asthma. 
Methods: Patients were between the ases of 17 and 43. All scored between S and 

10 on the Woods-Down i VV-Di asthma scoring system. Scoring includes 
inspiratory and expiratory sounds, accessory muscle use. SpO:. and level of 
consciousness. 4 patients were treated conventionally with 80'7(/209f He/O: at 20 
1pm using a non-rebreather mask (NRM) and nebulizer connected via a Y piece and 
one-way valves. The remaining 4 patients were treated with between 20 and .^0 1pm 
HeOx. warmed and humidified (37''C. 95'/f R.H.) by Vapotherm. and delivered via 
high How nasal cannula (HFNC). Medication was delivered orally from a small 
volume nebulizer. 

Results: All patients showed the expected vocal changes. One patient Irom each 
group did not improve SpO: or consciousness w ith treatment, and required Intuba- 
tion, mechanical ventilation and admission for 3 days or more. All the remaining 
patients showed improved breathing and SpO:. and were discharged within 24 hrs. 












pre/post pre/post 


















disch. 4hrs 





















































\ These results suggest that if HeOx 

IS warmed 

and humidiried. it ma> 

be administered as effectively b\ HFNC as by NRM, If a suitable humidification 
device is used, the NC method has several advantages. These Include: belter warm* 
ing and humidifying of the inspired gases; better tolerance by patients; ea.sler 
administration by caregivers; patients can drink and take oral medication without 
interrupting therapy; reduced anxiel\. If these results are confirmed in further stud- 
ies. HFNC may therefore be the preferred route for HeOx administration In acule 
a.sthma. OF-02-1 62 


ENVIRONMENT. John W. Berkenbusch ' . Ryan H, Grueber - . Gavin R, Graff ' . Joseph D. 
Tohms^-. Departments of Child Health'. Respiratory Therapy-, and Anesthesiology'. The 
Universitv of Missouri-Columbia. Columbia. MO. USA. 

INTRODUCTION: Interest continues to grow regarding applications of helium-oxygen 
I heliox ) therapy for both upper and lower airway disorders. Reports to date have focussed on 
the safely and effectiv eness of helium for specific disease prtKcsses but no data exist regard- 
ing general patterns of heliox use This report de.serihes ihe paiicms of heliox use in the ter- 
tiary eare critical care env ironinent of an acadenuc medical center 

METHODS: All patients receiving heliox therapy over a 4 year period in 7 critical care units 
t»f our Institution were enrolled. Data collected included patient demographics and location, 
indicaiion for heliox use. method of delivery, duration ol use and the rationale for it's contin- 
uation. Comparisons between use for upper versus lower airway disorders and between pedi- 
atnc (£18 years) versus adult applications were perfomicd by chi-squared analysis with a con- 
tingency table. A p value < 0()5 was considered significanl. 

RESULTS: Eighty-nine patients, aged 17.4+20.9 years (range 14 days to 82 years), received 
heliox for 30-5±44,(i hours (range 0,1-256 hours) on 92 occasions. Pediatric applications 
accounted lor lYk of heliox use, Heliox use increased progressively throughout the study 
period, primarily in the adult population where use almost doubled, Fortv -three {Al^k^ appli- 
cations were for upper airwav obstmction (UAOl. most coiiimonlv post-extubation stridor 
(n=22i, static encephalopathy (n=7), and croup (n=6). The mean duration of use of 1 5. 8± 17.0 
hours, Heliox was delivered by simple face (n=40), aerosol face mask (n=2l. orCPAP 
(n=] I. A positive response was perceived in 22/27 (82'^f ) children versus 6/16 (38*7^ ) of adults 
ip<0,00li. Ten patients (3 children. 7 adults) required endotracheal iniubation. Forty-nine 
(53*^1^ ) applications were for lower airway disorders, most comnionlv status a.sthniatlcus 
(n=3Sf and Respirator) Syncviial virus (RSVi hronehloliiis (n=4). The mean duration of use 
of 43.2±56-.^ hours (p<0.0()5 compared with duration wiih use hir UAO), Heliox was deliv- 
ered h\ aerosol face mask (n=30). simple face mask (n=l7) mechanical ventilator (n=6) or 
BiP,^? in=li. A positive response was perceived In .M/40 (85')r) children and 7/9 (78%) 
adults ip=NS), Four patients (2 children. 2 adults) required endotracheal intubation. Thirty- 
iwi) patients received heliox at an initial FiO; of >0.45. In 16 of these (50*^^1. FiOj was 
weaned by a mean of n,I3±(),f)5 within one hour of heliox initiation, 

CONCLUSIONS: This is the first senes descnbing patterns of hehox use in the ternary care 
critical care environment of an academic medical center, Heliox appeared tt> be far more 
effective for treating UAO in the pediatric compared to the adult age group. W hile heliox v\'as 
continued for a longer duration for lower airway disorders, the concurrent use of other thera- 
pies makes determination of a positive response in these patients more difficult. The rapid 
decrease in FIG; in many patients receiving heliox at relaiivelv high initial FiO; values sug- 
gests that heliox may be mi>re beneficial at higher FiO; values ihan prev iously thought. As a 
benign and relatively inexpensive therapy, heliox will likelv be^.onle increasingly attrac- 
tive for the treatment of many respiratory disorders, despite limited data regarding efficacy in 
certain scenarios, 


Respiratory Care • September 2002 Voe 47 No 9 


Critical Care 

Resuscitator ™ 


Major Advances in 

Airway Clearance IPPB Delivery 

PercussiveNEB ™ 
High frequency 
percussive nebulizer 

Portable inexpensive 

Home Care 


• Choice of Fi02 at 
50 or 100% 

• Reduced O2 consumption 

' Price comparable to 
manual resuscitator 

' Pressure cycled 
for breathing or 
non-breathing patients 

' Single patient multiple use 

' MRI & CT compatible 

' Adjustable pressure dial 

' For cystic fibrosis, 
COPD, atelectasis 

' Mucus clearance 

' High frequency oscillation 

' High aerosol output 

' Home or hospital use 

• For home, transport 
and hospital 

• No capital equipment cost 

• Uses standard hospital 

• High aerosol output 

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' Use with PercussiveNEB, 

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TEL: (800) 434-4034 
FAX: (916) 648-9751 
Website tittp://www.vortran com 

Circle 1 42 on product information cord 
Visit AARC Booth 844 in Tempo 

Sunday. 0(T()Im:r 6. 12:30-2:25 pm (Rooms 18-19) 

r. V. Kobels. Yii. Vii. Vasilciiko 
Crimea Medical University. Simreropdl, Ukniiiie 

Rise in the nunihcr ol imla\ lUiiablc uiiloi ctTccis makes liighlcncd 
demands icir the proteclivc systems ol children, inmume system in 
particular, that imder climatic conditions, is manilested by the increase of 
respiratory allergoses in Crimea (Ukraine). Search ot new methods of 
rehabilitation of children with OB appears to be actual. With the aim sci- 
entists of the Crimea worked out the biological active additions (BAA) 
"Biotrof 4" and "Bipolan."The purpose of our investigation was to study 
the role of BAA "Biotrof 4" and "Bipolan" in complex rehabilitation of 
1.10 children (7-14 years old) with obstructive bronchitis under the con- 
ditions of sanatorium. Immunologic investigation of the cellular, 
humoral, nonspecific immunity was conducted in dynamics. The therapy 
mcluded sun-bathers, bathing in sea. valuable nourishment, sanation of 
the foci of infection (electrophoresis, throat gargling with therma- 
mineral water). 39 children also took the natural product "Biotrof 4" and 
40 children took "Bipolan." On addmi.ssion in the sanatorium the 
children with OB revealed the lowering of Ig A and increase of Ig M. 
that testified the presence of antigenic load (21% of children had the foci 
of chronic infection). The absolute nuinber of T-lymphocites was 
decreased. .After rehabilitation all chidren revealed the improveinent of 
general condition and immunologic indexes, but the number of CD-3 
(the total number of T-lymhocitesi and phagocitis activity only became 
normal in children getting "Biotrof 4" and "Bipolan." The latter allows 
us to recommend to include "Biotrof 4" and "Bipolan" into the medicinal 
and prophylactic nourishment of those being in poor health because of 
respiratory diseases. 



Roherl Leshko. RRT : Kcnncili Miller. RR I . Mlul; Lawrence Mann. RR P; SIl'xcii Pvik-. 
RRT.BS; Gail Rninsi. CC See, I .chi(!h Valley Hospital Center. Allcnlmvn, PA IXIIIS 

liitnHluction: Caixliopuliiioiiaiy ivsuscilalion (CPR) ivt|uiics a larjic antounl nlholli 
L-qiii|imL-iil and |X.■l^oll^cl ivsmuves. OIIl-ii ihciv isdt'hale a'^artliny Ihe pniix'i utili/ation 
111 these lesiiuivcs iuid when CPR w ill must likely Ix- ncciiai. Tliis inlnnnaliun can pmvc 
useful lor scheduling ivsourees and predicting ouleonies, ll also allows lur a'soiution ol 
disagiveiiicnLs n.'gaaling which shiti lurs more code blues ami best outcomes. Methods 
and patients; Wc perlbnned a annispeetivc review ol all code blues thai tK-eum-d at our 
in-.iiluiion (.s.sO bed (caching medical center) during a one-year lime span. We examined 
loial ouicomes. outcomes for monitored :uid noii-monitored patients. Ca'queney per day of 
week, frequency pertime olday. and patient gender Results: There was a total of .12S 
cixte blues reviewed lor the one-year penod. 

Total codes 



147(4.S'7, ) 


14') 1477, ) 

101 (69':<) 



46 (.11%) 






64 (69'i 

Day of H eek 



lime of day 






01)0 1-0401) 






















.16 111'^;) 








20n 1-2400 






Conclusion: More males than lemaies required CPR and a female's chance of sury i\ al 
was gR'aier. As expected, monitored patients had a higher sunival rate than non- 
monitorcd patients. Monday and Tuesday had the highest number of codes with Tuesday 
having the highest survival rate. The time peritxl between 0801 -1 200 had the highest \oL 
ume of ctxies. but also the lowest survival percentage. Results regarding CPR frequency 
;md outcomes can give valuable information regarding equipment and personnel alloea- 

"""■ OF-02-023 

What Works and How Effective Are Better Breathers Clubs? 

Bob Langenderler MEd. RRT 

Background: Better Breathers Clubs (BBCs) are meant to provide 

ongoing support, education, follow-up. and social interaction during 

phase three of pulmonary rehab. How effective are BBCs. w hat 

speakers, topics, meeting times and activities do patients want, and what 

barriers pre\ent more participation in BBCs? 

Method: .A total of 1 820 surveys were distributed at the meetings and 

through the mailing lists of the 1 2 active BBCs in the state of KY. 

202 completed surveys were returned. Respondents were 42% male and 

-5X% female: 70'7r had some form of COPD. 

Results: I. BBCs were judged worthwhile by a random mix of regular 

and infrequent participants, w ith an overall rating of 3.33 on a 0-4 scale. 

2. The preferred meeting lime is afternoon (41 .5'f ). late morning 
(30.8"^?-). and early evening (27.7':r). 

3. Meeting formats were ranked: 1. (top) informational talks by health- 
care professionals; 2. capable patients describe how they cope; 

3. meetings with both educational and social activities; 4. motivational 
talks by caring laypeople; ,5. fun activities like crafts or games. 

4. Main reasons patients don't go to BBC meetings: 1. (top) other 
lamily obligations; 2. not enough energy; 3. none available in the area; 

4. too sick; .5. inconxenient meeting sites; (i. too far to go. 

5. Reasons for regular BBC participation: 1. (top) to gain info 
presented; 2. to get professional support; 3. to help one cope emotionally; 
4. BBC activities make one feel less isolated; 5. at BBC meetings one 
can build supportive relationships with other patients. 

6. Ranking of speakers: 1. respiratory therapist; 2. doctor; 3. physical 
therapist; 4. dietician; .5. nurse; 6. pharmacist; 7. humorist; X. a 
capable patient; 9. mental health counselor; 10. social worker. 

7. Topics of greatest interest: I . nutrition and SOB; 2. relaxation tips 
to control SOB; 3. breathing and coughing techniques; 4. early warnings 
of lung infection; 5. modifying daily activities to reduce SOB; 6. easy 
exercises; 7. understanding medications; 8. family adjustments to 
chronic lung disease; 9. medication management; 10. meaning idPFTs; 

1 1 . traveling with oxygen; 1 2, ad\ ances in oxy gen therapy. 

8. Preferences in social functions: 1 . play bingo; 2. have a potUick din- 
ner; 3. take bus lour; 4, go im picnic; 5. go to a play; (S. make crafts; 7. 
invite a choir to perform; S. play cards; 9. go on cruise or to a concert. 
Conclusions: Patients find BBCs very worthwhile for many reasons, 
and they enjoy a variety of activities. BBC availability is the greatest 
problem. bF-02-057 



Kimberly M Kingsley, RRT, MA; Maine Medical Center. Portland, ME 

Background: Critical care respiratory therapists are exposed to significant amounts 
of death, dying, and trauma I hypothesized that this exposure will have a 
psychological impact on the clinician and that there are supportive elements that an 
msUluUon can provide to reduce the negative impacts Further, individuals develop 
their own coping mechanisms that I wanted to discover 

Method: I distnbuled an original questionnaire to 55 respiratory therapists Topics 
covered by the questions included I Rating 10 aspects of stress within the hospital 
environment, companng the level of stress caused by exposure to death, dying, and 
trauma to other elements in the work environment, such as interaction with the 
supervisory group, 2 Suppori mechanisms provided by the institution, and 3 Coping 
skills developed and employed by individual respiratory therapists 
Resultai: The return rale for my questionnaire was 43% (28 of 65) 1 analyzed the 
data in aggregate for the whole group, and then broke the group down into three sub- 
groups in order to analyze the data further These groups were based on years of 
experience Group A (0-5 years. 6 total responses). Group B (6-15 years. 10 total 
responses), and Group C (16 or more years. 12 total responses) I found that the 
cumulative effects of exposure to death, dying, and trauma are less stressful than the 
stress of feeling unsupported by their supervisory group I also found that there were 
more responses in common between Groups A and C than in Group B 
Conclusion: This study is limited by the small study size so that results cannot be 
generalized to all cntical care respiratory dierapists Data was evaluated in a 
qualitative manner trying to facilitate a more formal support system Based on 
responses 1 recommend the fomialion of a more formal support system utilizing 
elements requested by the respiratory tlierapists them.selves. 


Respiratory Care • September 2002 Vol 47 No 9 


Sunday. October 6. 12:30-2:25 i*m (Rooms lS-19) 

Preparine f or Mass CasualliM & Mtchankal Vi? nlilali<in Allyrnalives 
Dave Swift RRT. RRCP - Senior Therapist 
Ollawu Hiispilal. OltaHa, Ontiiriii, Canada 

The MilKh 1995 Ti)kyt'. Jiipiin Icrninsl ;ilUii.k umiij; llic nerve aycni Sarin sDundcd a wakcup call in 
hcallli care workers. The inlcntjonal release of this neurotoxin resulted in 1 1 dead and five thousand 
exhibiting toxic symplonis. The health care system was rapidly overwhelmed' 

Tile National Capital Region of Ottawa is home to embassies ot many nations and is viewed as a 
very high nsk tor a terrorist attack. As the sole Respiratory Tlier;i|iisi if|irescnlative on the Chemical, 
Biological, Radiation and Nuclear Cinnmitlee, it became rapidly app.ireni thai there was a serious dis 
crepancy between the number ol ventilators available and the actual ventilator resources available. 
Mils t'liuic limit was determined to be both unacceptable and avoidable. To avoid compromising 
palieni care a cost etteclive method for treating the largest number of patients had to be determined 

It was determined that a pneumatic, automatic rcsuscitalor ottered the best clinical options. As it 
U.1S not dependent on a/c power, was highly ptinable and relatively easy to use it seemed the most 
appropnale. cost effective choice. 

The units were tested using the following clinical simulations: increased rtsistance. decreased com- 
pliance, increased compliance and with an air leak present All units performed as advertised when 
faced with incrcitsed compliance, with delivered volumes decreasing and rales increasing with 
mcrcised resistance and citmpliance Senous clinical problems would be encountered with air leaks 
piesi'iit and would need prumpl inedKal intervention Although all three units jTerlurmed as 
.idverliscd, each unit had individual characlensiKs that would have to be evaluated by the potential user 
as suitable for their own clinical applicjiions 

The Voriran Automat ic ResusLiiaior ullercd the capabilities of managing the largest number of 
patients at the most financially responsible cost. In addition, the unit has the advantage of ease of usl- 
and thai the equipment nflered a simple solution to the handling ot contaminated units from a biologi- 
cal or Icmmsm mcidcnl. il is disposable. The costs of the other units prohibited one time use and 
would rcsull in a Icnylhy and expensive decttnlaminalion priKCss, which might also pose a hazard to 
hospital staff charged vMlh deconlammaiion 
Characlerislics Required In A Mass Casualty \ entilalor/Resucitator: 

Patient Type 


l.l NiSiS 11 




Pcdi-iiriL 1^.1 vrs) 
and adiill 

Pedi.ilric t>3 years) 
and adult 

Pediatric i>l vearsl 
and adult 

'nwer source 





<! 5 Ih 

<2 Ih 






volume LVcleJ 




i:or :i) 



\nli>.ult.H..iiiMn valve 




pressure rclicl 





ves iiipnonall 





It )2 cnntr.'l 

fiilnr Hid'- 


.sOmf KmV, 



Mni;li,7niulliple use 

mulliple pts 

multiple pis 






rcpljccmenl pjrls 
required ii CT scan/ 

\es ivalves.elcl 
Not certified lorCT 
Scan or MRl use 


Not cemtred lord 

Scan or MRI use 


Certified for CT 


VaTIrcIsp, yccli'i^.'Manut^lurcr. 

ir, .^ in T..kvi>. No* Y.'ik WV.irhL-rhill, Ini IW^ 

cr AmbS in^- Linihicuin. MD, US-\ 

)2 Sjslems Iqc.. MiNM\s;iut:.^ Oniunn, Cjni|d.i 

orlnin McdiCuf Tcchriuluyy. Sjcranicnin, Califomm. U.SA 


the influence of fev,., of predicted on tol- 
i:r.\nce in older adults with chronic ob.structive 


Sidney R Schneider PhD RRT RPFT . Roben L Joyner PhD RRT. Susan 
M Muller PhD. Jeanne E Ruff MS. Salisbury University and Peninsula 
Retiiiinal Medical Center. Salisbury. MD 

Back}>ri>(ind: The FEV|.; of predicted is frequently used to determine 
seventy of disease in chronic obstructi\e pulnion;uy disease. The purpose 
of this study was to determine the impact of se\erily of disease, as 
measured by FEV|, of predicted, on exercise tolerance in older adults 
with COPD completing a pulmoniiry rehabilitation iPRi program. Meth- 
ods: A retrospective study was conducted to examine exercise tolerance 
records (comparing initial and final sessions ) ol 51 adults. 59 to S 1 years 
of age (mean ± SD = 69.4 ± 6.1 years). 29 females and 2S males, with 
COPD grouped according to severity of disease (mild, n = 21; moderate- 
severe, n = .'^6) based on FEV|.; of predicted, thai completed .^6 one-hour 
exercise sessions in an outpatient PR program (time to completion Mean ± 
SD = 4. 17 + l..'i2 months.). Results: Analysis by repeated measures 
ANOVA found improved exercise tolerance within subjects (p = < 0.05) 
for both groups for treadmill workload (mph). treadmill time (min.l. 
stationary cycling workload (by level), cycling time (min.) and 6-minule 
Walk (mph). The groups differed only on the 6-minute Walk (p = < 0.05). 
There were no differences in 0^ saturation, rate of perceived exertion, dys- 
pnea rating, body weight, or months to completion. Differences between 
groups (paired t-lests. p = < 0.05) were found for FEV). FEV,.; of 
predicted. FEV|/FVC ratio. FEF15.75 FEF:s.7s<i. but not age. Conclusion: 
Improvements in exercise tolerance in older adults participating in PR 
were found across severity of COPD. However, grouping subjects by 
FEV|.; of predicted failed to differentiate improvements in exercise toler- 
ance between groups for all measured parameters of exercise tolerance, 
except for the 6-minute walk. This may suggest that other factors hav e a 
greater inlluence on exercise tolerance in exercising older adults with 
COPD. OF-02-076 


EJv^;tfd C. Bums. RRT. CPHO ; Annand D. Riendeau. RN. RRT. Eileen Halev. 

RR I\ Dean Hess. Ph.D.. RRT. Robert M. Kacmarek, Ph.D.. RRT, Massachusetts 
General Hospital, Boston, MA and Spaulding Rehabilitation Hospital, Boston, 

Introduction: At this rehabilitation facility, patients on respiratory care serv ices 
;ire classified into two major categories, eoniplex-niedicai and non-complex medi- 
cal, based upon a respiratory care needs algorithm. All patients classified as com- 
plex-medical receiv e their therapv from a respiratory therapist until reclassified as 
non-complex medical, at which time they receive therapy from a registered nurse, 
A standardized approach to assessing and tracking progress was required. The Res- 
piratory Assessment Scoring System ( RASS 1 \\ as developed to prov ide the respi- 
ralorv therapist w ilh a standardized approach to measuring patient's acuity and 
then reh.ihilil.itive progress dunng their stay on respiratory therapy services. 
Method: .A sconng grid vv as designed to assess ten categories consisting of five 
clinical and five rehabilitative ftK-used aspects of care. The clinically focused cate- 
gories consist of breathing pattern, breath sounds, cough effort/abilitv. sputum, and 
oxygen requirements. The rehabilitative categories consist of level of patient activ- 
ity, mental status and leiiming capability, the knowledge of therapy and 
prwedures. compliance and cotipcration. ability to return demonstration. To verily 
the inter-rater reliability, we randonilv selected 60 p.itienls. The senior respiralorv 
Iherapist assessed each patient vv ithin I .s iniiuiles lollnwing a siafi therapist's eval- 
uation. The senior respiratory therapist was blinded to the original RASS score. 
The validity of the RASS scores was established by ci)rrelating the patient's initial 
RASS score with LOS on respiratory therapy. LO.S on respiratory c;ire serv ices. 
LOS in hospital, and total respiratory care ch;irges. The R.ASS system was 
incorporated into the current respiratory care computerized dep;irtiiiental hilling 
system and workload distribution program. Each category is assigned a weight 
from zero and increasing in severity to a score of four. The patients are divided inti> 
four categories based on their ov erall RASS score. Category 1 R.ASS scores fall 
into the l)-S range, category 2 in ihe 9 17 range, category .^ in the I X-.% range and 
category 4 in the 27-40 range. Results; RASS was tested for inter-rater reliability 
vv ith a correlation coefficient ol (),9 1 . a mean difference of -0, 1 and a standard 
dev iation ol 2.2, R.ASS vv as also tested lor v alidity and demonstrated a nnxlerate 
degree of correlation between the initial admission date R.ASS score and tlie LOS 
on Treatments, LOS on Respiratory Care Sen ices and LOS in the hospital, vv ith an 
average coefficient correlation of l),6(), Cunelusinn: Dailv utilization of the R,ASS 
assists with preparing a more elleclive disiribulioii and piionlizalion of work 
assignments based on acuity and assists vv ith the p.itieni care planning process and 
shifl reporting. It also prov ides managemeiil wilh a (ixil to quickly gauge the over- 
all workload, as well as. patient acuitv , In addition, it enhances the reporting of priv 
ductivity numbers by allowing an adjustment based on acuity. OF-02-1 06 




Ryan E. Gmeber. BS. RRT , Andrew W. McKibben. MD. Karl J. Orscheln. 
MD. University of Missouri-Columbia. Columbia. MO. USA 
Introduction: Data demonstrating both health effects and ptipular demand 
has resulted in increasing restriction of exposure to tobacco smoke. Many 
health c;ire institutions in the United States frequently describe the 
env ironment prov ided lor patients and employees as "Smoke-Free." We 
investigated the concrete criteria of these policies in a survey of academic 
medical centers in the United States. 

Mcthixls: Data vv as obtained from policy and procedure manuals available 
on-line and by indiv idual responses elicited through established health c;ire 
list-servers. We defined a smoke free facility as one, which allowed no smok- 
ing by patients or employees anywhere in the health care site, including the 
grounds outside of the facility. We defined li self-describoil smoke free center 
as a center that used the term. "Smoke Free" in then institutional smoking 
policy. To be eligible for inclusion as an academic center the facility had to 
be listed in the AAMC Medical Education Geogmphical Listing of Medical 
Schools, Mental health institutions were exckuled. 
Numberof facilities included > 20 

Self Described as Smoke Free > 60% 

Smokini; Allowed in Desianated Area > 85% 

Totally Smoke Free ' > 15% 

Discussion: In developed countries, smoking is the most preventable health 
risk known and is an important cause of premature death worldwitle. U.S. 
Academic health centers are the world leaders in health c;ue initiatives. Data 
has show n that employers that eliminate work place smoking have seen an 
increase in employee smoking cessation rates. 

Conclusions: V\hile a majority of suiveyed institutions describe themselves 
as "Smoke-lTee." only a minonty of centers lorbids smoking completely. 
While some institutions appear to contemphile not permitting smoking lor 
patients or v isiiors. certain exceptions, such as allow ing smoking outside on 
hospital grounds may be driven by demands of employees or other considera- 
tions, 1-uilher education and efforts to promote smoking cessation appear 
needed hasetl on the results of this prelimin;iry survey . Tliis study is a small 
example ol the potential of the Internet as a tool for academic rese;u"ch. 

OF-02-1 09 


Respira roR^' Care • September 2002 Vol 47 No 9 

SUNDAY, OCTOBl'R 6, 12:30-2:25 F'M (ROOMS lS-19) 

K\idciice-Based HnjliK-ftUiukk-d Rehahilitalion of 

\ t'nliliilnr-IK'iX'iKicnl Spinal dinl Injuru) Patients - A l*ilut Study 

ChaHi.-W.tiuti'.-rTi.v^MS J<EI. Jflla-v H.imiw. MD. PhD. 
IrctS Haiiu-s. KK I. .imi Joy Jiia-na Willianis. RN. RRT. MHS 

J.imcN A. Halc) Vcicr<uis' Hospital. Rcspiralon. Oin: & Diagnasiic Sen ices, SCI / 7N Sub- 
Aculc Ciirc Prucrani. and Spinal Coal Injury / Dysfunction Senicc. Tiinipa. M. 3.^6 1 2 

IntTXHiiictiyn : i-AnJcncx'-hascd la.hniqucs were used lo develop .ukI implement a clinical pro- 
tiKol lor impRn ing respiratory tnuscle sia-ngih of ventilaior-depciulL-ni s[ cord injuad 
patieiiLs pa-p;inni: for weaning fmm iJK\:hanical \cnliiaUon. Results from the first 4 putienis 
are pa'sented 

Methods and Vtatenak : A thomugh liieralure scairh was performed to obtain scientific arti- 
cles .iNhiI luiicotnes 111 ventilator \\e;iiiinji Articles wea- rated in teniisof their i|ualily and 
applicahilii\ While main slmlies examined the value of a-Mslancc training or cnduraiKe 
training, iiopmiocol comhined ht>th of these- Based on e\ ideiiee ot etiectivc nicthixls, a pro- 
tiKol WiLs de\ eloped ilial encompassed nutritional parameters, resistance training, and 
endurance training. ImliLsion criteria: ventilator-dependent spina! cord injua-d patients, medi- 
call\ siiihle Ku ItiMon criteria: age > 70. unable to cwperate. Proiocni. Prior to initiating res- 
piratorv a-hahilitation cxca'ises, nutritional panuncters \vere examined. Patients with abnor- 
mal pa'-albiimin underwent intensive nutritional support ranging fmm lube feeding 
supplements to patient-initialed eating. After nonnalizatton of pre albumin, patients with 
abnonnal albumin underwent liver function and pmstale specific antigen ;Lssays before being 
pliicetl on Oxandmlone. an anabolic steaiid. Inspiratory resistance strength training was per- 
fomied in a pmga'ssive manner using a commercially aviulable de\ ice. Endurance training 
consisted of on -vent breathing with pressure support (PSV 5) and continuous positive airway 
pa-ssua- 1 CP.AP 5 ), pa>gressmg to off- vent weaning trials is tolerated. Patients wens 
maintained w uhin pnMocol parameters. In the event of intotenince patients were returned to 
Assist / Contail mode for at least 24 hours. 

Results : Patients (n=4j with incomplete cervical spinal cord injury (C2 -CD underwent respi- 
raiorv rehabilitation for 3 lo 1 2 months Indices of respiratory muscle sUiength including maxi- 
mal mspiratorv pa'ssure iPiM AX ) ;md vital capacity ( VC ) wea recorded before and after par- 
ticipaiinam the rehabilitation pn^gram. Pa' albumin (Pre iilbi was moniton^d as an index of 
muscle repletion ;ind a'admess, 7S'r of patients progressed to ol f-\ ent weaning triids and 50'> 
remained t>ff vent for 5 or more hours per day. 






p \ aiue 












< 05 

Pre alb 1 nig /(ID 






Conclusion : .\ review of the literature using evidence-ba.sed techniques lead to development 
and implementation of"pn)t(XoI-guided rehabilitation for vent-dependent SCI palient.s. Nuun- 
tional nonnali/^ition. resistance and endurance training constituted key elements of the proto- 
col. t\ idence-based protocol guided rehabilitation of vent-dependent spiniil cord injured 
patients resulted in signiticantly improved respiratory muscle strength OF-02-132 

CARE MEDICINE. Alexander Adams MPH. RRT . Regions 
Hospital/Univ of MN. St. Paul. MN. Background: .An established, 
accepted system for recognition and comparison of research 
accomplishments of major investigators in pulmonar\'/critical care 
medicine does not exist. Access to the publications and citations of 
investigators is readily available through the National Institute of Health 
and via the Science Citation Index. This study analyzed the 
publications/citations of the 60 leading investigators in pulmonary/criti- 
cal care medicine. Methods: A recent investigator list was compiled by 
examining authorship of publications in AJRCCM, Chest, Respir Care 
and CCM. The number of publications and all citations of their works 
within the past 5 years were tallied. Publications included original 
research articles, editorials, reviews and consensus conference proceed- 
ings. Letters, replies and meeting abstracts were excluded. A country 
analysis was also completed of ATS meeting abstracts in the area ot 
mechanical \entilation(abstracts/country/million pop). Journal editors 
were excluded from the analysis. Results: The leading investigators in 
number of publications were Matthay-IO.^, Slutsky-VJ, Pinsky-70, 
Kollef-62 and Brochard-58. The greatest nuinber of citations were 
received by Slutsky-I.'149. Matthay-1269, Kollef-724, Brochard-4S0, 
and Dreyfuss-478. The highest impact factor (citations/publication) 
were attained by Dreyfuss-16..'i, Suter-14.9, Gatlinoni- 12.7, Malthay- 
1 2..^ and Jubran- 12.1. The leading countries in mechanical ventilation 
abstracts were Canada-. 55. France-.3I, USA-. 27, Spain-. 2.'? and 
Taiwan-. 19. Conclusioas: This report acknowledges, in a quantitative 
manner, the leaders in pulmonary /critical care medicine over the past 3 
years by three criteria - publication #, citation # and iinpact factor. A 
country analysis recognizes the leadership of Canada. France and the 
USA in the field of mechanical ventilation. 


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Timotliv M\cp- B.S, RRT ,ind Carolvn Ketcsmar MD, 
Rainhow Babies and Children' s Hospital and Western Reserve University, Cleveland, OH 

Introduction: The concept of experimental validity is a concern with conclusion 
accuracy in a research design. Often studies are conducted in a douhlc-hlind approach lo 
eliminate threats to external validity from study-effect or investigator biases. Another 
hypothetical threat to study validity is the patient(s) becoming unblinded in a 
randomised conUollcd mal and tipping off the investigators. In a double-blind, random- 
ized mal comparing the acute treatment of pcdiaunc asthma with two types of albuterol 
( racemic albuterol and Icvalbuterol 1, we sought to dctemline the ability of patients or 
their parentis) to correctly break blinding ol their riindomized albuterol type. 

Methods: In a double-blind, randomi/cd conuol tnal of .'i,'i2 asthmatic patients, we 
sought to detemiine if Icvalbuterol resulted in improved clinical outcomes compared to 
racemic albuterol. Patients who consented for participation were randomized in a dou- 
ble-blind fashion to receive either 2,-'i mg tilbulerol or 1 .2.'> mg Icvalbuterol delivered by 
a high-density Nebulech (Salter Labs, Ii\'inc, Ca. 1 nebuli/er. We utili/ed our 
assessment-driven Asthma Carcpaths to sUtndardize UeaUnent between groups. For the 
purpose of this study, a small convenience sample ( 25% or 1 1 .1 ) of patients and/or their 
parents were provided a questionnaire asking them to attempt lo identify the foml of 
albuterol (racemic or Icvalbuterol) prescnbed lo ihcni/iheir child for the acute ueamient 
of their asthma exacertiation. Que.stlonnain; respondents wen; also given a list of quali- 
fying reasons for their selection of a specific type of albuterol. Nominal data was 
antilyzed for sensitivity and specificity, positive and negative predictive value, and diag- 
nostic accuracy. Kappa and Phi coefficients weie used to assess for reliability between 

Results: All 1 1 3 surveys were returned. The figure below is a breakdown of the pre- 
dictive test for the rcspondenLs' answers to type of medication they/their child was 
receiving. Thirty-four (30.1':? ) questionnaire respondents stated ihcy were "not sure" of 
the albuterol type. Fifty-two (46<7t I reported taking Icvalbuterol. while 27 (23.9% ) 
patients rcpi^rted taking racemic albuterol. Percentages for sensitivity and specificity 
were 31.8*^ and 62. S'^ ^^spectiveIy. Positivcpredictivc value of the responses was 
-5 1 .9%, while the negative predictive value was 42.3%. Diagnostic accuracy was 52. 1 9f . 
Reliability testing by Kappa coefficients yielded a value of 0, 1 8. Reliability testing by 
Phi coefficients yielded a value of -0.056. 

Confirmed Medication 1 

Uuestionnairc Response 

Rill eniic Alhiilenil 


Racemic Albuterol 






Conclusion: From the results 
type of albuterol thcy/their ch 
than that of chance guessing, 
sub-sample that was survcyec 

above, the respondents' .ibilily lo .iccur.itcly predict the 

n this study, patient blinding was adequ.iteh achieved in a 

■ OF-02-168 











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Sunday, October 6. 12:30-2:25 pm (Rooms 20-21 ) 


Nathan Lew is. CRT & Wayne Wallace. MBA. RRT 

Kaiser Peniianente Bellflmver Medical Center. Belltlower. CA 

B.\CK(;R()UND: Kaiser Pemianente's Belltlower Medical Center is an 
acme c;ire hospital serving the HMO's memhcrs in the Tri-Central Senice 
Area. Ttiere is an out-patient case nianagcment program pro\ ided hy a single 
RCP. which serves primarily adult patients sufl'ering from chronic King 
disease (predominately asthma and COPD). MK'I'HODS: The case manage- 
ment program monitors the patients' control ol their under!) ing chronic lung 
disease lelephonically . Patient care plans ;u"e niodil'ied using a protiKol or the 
patient is referred to their pniiKU") physician for lurther care or e\ aluation. 
Patients' utilization patterns were monitored for a year prior to and post p;ir- 
ticipation in case management. Some patients were new menihers to the 
HMO and did not ha\e a complete ye;ir of enrollment prior to being refened 
for case management (thus p^irtial >e;ir data was presented). All differences in 
adiTiissions. ALOS. and days utilized were highly statistically signillcanl /)■ 
niliif < .(K)l. There was no statistically significant difference in the rate of 
readmissions to the hospital w ithin 7 day s as a result of the program. A sum- 
mary of the program's results over the past three ye;irs is presented in tabular 
fomi below : 

Fiscal Year 
















37 1 












Days Utilized 







P'XPERIENCE: RCP directed case management was able to reduce not only 
lung related health care utilization but overall utilization as well. Average cost 
per day of hospitalization ( inclusive of facility overhead ) for chronic lung dis- related DRGs is $1,593.33 at Kaiser Peniianente Bellflower Medical 
Center. Tliis u-anslates to a provisional cost savina estimate of $ 1 ,0 1 9.73 1 .20 
for F\'9S, S446. 1 32.40 for R' 99, ;ind $44 1 .352.4 1 for FY 00 respectively. 
The estimate is limited by the inclusion of non-lung disease admissions in the 
data. CONCLUSIONS: A program utilizing a RCP as a case manager has 
demonstfated an overall reduction of hospital utilization by chronic lung dis- 
ease patients and resultant positive economic impact. _P -_ „_„ 


Jeiry Saldui-iti. CRT & Wayne Wallace. MBA, RRT 
Kaiser Pemianenle Ltis Angeles Medical Center. Los Angeles, CA 

BACK(;R0UND: Kaiser Pemianente's Southern California 
Region consists of I I acute care facilities, regional offices, and 
associated primary clinics. The Dcpartiiiciit Administrators (DA) 
and the Assistant Department Administrators (ADA) lor Respira- 
tory Care meet on a i|uarlerly basis lo discuss issues of mutual 
concern. In the summer of 2001 . the respiratory care DA's and 
ADA'S discussed the increasingly dil'ficiill situation in recruiting 
Liualified RCPs with neonatal experience. A decision was made 
to create an educational program designed to transition existing 
adult critical care RCPs into state-of- the-art neonatal care. 
METHODS: A 2-week didactic educational prograin followed 
by 6()-hour clinical rotation was given to a group of adult critical 
care RCPs selected based on their professionalism, motivation, 
staffing needs, and seniority. A post program survey was 
conducted approximately one month post program completion. 
RESULTS: 14 RCPs were initially enrolled. 1 RCP did not suc- 
cessfully pass the final exam, and 1 RCP simply audited the 
course. 8 RCPs returned the post survey and indicated that they 
were working regularly in the NICU. 3 DA's returned the survey 
and indicated that the RCPs trained by the program were 
functional NICU RCPs. Aneedotally.'both the RCPs and their 
managers voiced satisfaction with the program. EXPERIENCE: 
Socal Regional Respiratory Neonatal Program's initial program 
appears to be successful and may be an asset in the struggle to 
recruit and retain c|ualified neonatal RCPs. The prograin has also 
enhanced communication and rapport between all the facilities. 
CONCLUSIONS: A regional program was developed and 
implemented that facilitates the transformation of adult critical 
care RCPs into neonatal RCPs. OF-02-003 


Fedrual Harrison. RRT. Chay Robinson. BS. RRT. 

Louisa Ouicho. BS. RRT. & Wavne Wallace. MBA. RRT 

Kaiser Penmanente Harbor City Medical Center. Harbor City. CA 

BACKGROUND: Kaiser Permanente's Harbor City Medical Center is 
an acute care hospital serving the HMO's members in the Tri-Central 
Service Area. There is an out-patient case management program 
provided by RCPs. which serves primarily adult patients suffering from 
chrome lung disease. METHODS: The case management program mon- 
itors the patients' control of their underlying chronic lung disease either 
telephonically or via home visits. Patient care plans are modified using a 
protocol or the patients are referred to their primary physician for further 
care or evaluation. All information pertaining to the patient visits/calls, 
care plan modifications, or physician referrals are maintained in a com- 
puterized relational database. RESULTS: A summary of the program's 
results over the past four years is presented in tabular form below: 







Medication Chanae 





Steroids Ordered 





Antibiotics Ordered 





Sputum Done 





Trach Changes 





Oxygen (initiated, DC. Al 





Dischariie Referrals 





Provider Referrals 





Referred to Other HCP 





ABGs Drawn 





Logged In Calls 





Total # of Patients 





Tola! # of Home Visits 





A\e # of Home Visits Per Day 





EXPERIENCE: RCPs independently assess patients and have prot 
to initiate/change/discontinue therapy. CONCLUSIONS: A model 
gram utilizing RCPs as case managers has demonstrated its 
long-term feasibility for this patient population. OF-02 



Richard Treat, M.D., Beverly Maloney, RN, MSN, CNS, Deborah Elliot, 
RN, MSN, Fairview Hospital, Cleveland, Ohio 
Background: Stabilized patients who no longer require the level of 
care provided in an ICU setting are transferred to our nursing divi- 
sions. There was a perception that a disproportionate number of 
patients returned to the ICU for respiratory related complications. 
Benchmarking data confirmed this. Our return rate was 1% 
compared to the benchmark of 3.89^ . Of those that returned, 45% 
were due to respiratory complications. The remainder were for 
post-operative problems. GI bleeding, or blood pressure irregulari- 
ties. Most returns occurred 24 - 48 hours post-discharge. Unless the 
patient was ordered to receive respiratory care, RT was not likely to 
be involved in the assessment or care of these patients. Methods: A 
team (RTs. RNs. and physicians) was formed to identify causal fac- 
tors of recidivism. An evaluation tool was developed to identify 
those patients at risk for return to the ICU. It was validated in a pilot 
program during which all patients were screened prior to transfer 
from the ICU. This high-risk evaluation tool considered inspiratory 
volume moved using an IS, PaCOi. oxygen saturation, and respira- 
tory rate. A numerical value was assigned lo levels within each cat- 
egory. If a patient had a score that was classified as high risk, they 
were placed on an oxygen and/or hyperinfiation algorithm. These 
algorithms were stniclured to provide the patient with the appropri- 
ate therapy. RTs collaborated closely with unit-based RNs follow- 
ing the transfer of a patient from the ICU. Results: The return rate 
to the unit during the study period ( 1 2 months) was 3.75% 
compared to 6.249r pre-intervention. Conclusions: There are many 
variables that impact whether a patient will return to the ICU; some 
are w ithin our control, and others are not. This demonstrated that a 
multidisciplinary team could address a problem and do so without 
adding staff members or increasing an already considerable patient 
load. We continue to monitor this and hope to report its progress in 
the future. 


Respiratory Care • September 2002 Vol 47 No 9 


Sunday, October 6, 12:30-2:25 pm (Rooms 20-21 ] 

Douglas K. Orcns. RRT. MBA. James K. Siollcr. MD. MS. FAARC. The Cleveland 
Clinic Foiindaliim. Clc\cland. Ohio. 

Introduction: In ihc conlcxt of increasing atlention to medical errors, missed therapies 
ha\e become an object of ftx-Us both for optimizing clinical care. Because the issue of 
missed irvatmeiiis in respiratory therapy has received htllc attention to date, we under- 
took this descripli\e study of the frequency and causes of missed respiratory therapy 
medication treatments at the Cle\ eland Chnic Hospital 

Methods: Between August 2f)0()and August 2()*)l. the number of respiratory therapy 
medication treatments ordered, both small volume nebuli/ers (SVNs) and metered dose 
inhalers (MDIs). and the number of treatments delivered were recorded usinti our respi- 
ratory therapy management information system iCImiVision. Nellcor/Puritan Bennett. 
Carlsbad. California). Through the CliniVision system, we also documented the thera- 
pist-recorded reasonfsl for each missed treatment. 

Results: Over the 1 2-month study interval. 74.92 1 SVN treatments and 38.633 MDIs 
w ere ordered, for a total of 1 1 3.554 bronchodilalor medication treatments. Overall. 
4.012 medication treatments were missed (3,50^ of total), with variation by month 
ranging from 2.0% to 5.0%. Table 1 presents the reported reasons that aerosolized 
medication treatments were missed, according to 8 coded reasons. 

Table 1. Reported Reasons That Treatments Were Not Given, and % of Total 

Reasons Treatments Were Missed ( sec legend helim lablc ) | 





















t}S'-, 1 



n.2^; 1 






Legend: I. Patient not in room, 2. Patient refused (reatinenl, 3. Patient 
dischar):ed. 4. Patient unavailable, 5. Therapist advised not to give, 6. Breath 
sounds clear, 7. 1'nahic to tolerate. 8. Therapist called avsay emergently 

The commonest reason for missed bronchodilator treatmenls was the patient's being 
out of the room at the time of the RT's visit (31.6'^). Next most common was the 
patient's refusing treatment (24.6%), followed by the patient's being unavailable 
because of other activities or therapy (2n.?9f ). The least common reason was the respi- 
ratory therapist's being called away for other urgent care ( 1 .49r ). 
Conclusions: Overall, the frequency of missing bronchodilator treatments was 
relatively low in this senes. Based on this initial understanding, next steps include the 
need to develop strategies to further lower this frequency so as to optimize the alkKa- 
tion of respiratory therapy services, and the need to better understand the clinical con- 
;equences of missing respiratory therapies. OF-02-014 


RFi>PIRATORY CARE. Richard D. Rice. B.S.. R.R.T .. Lucv Kcster. 

M.B.A., R.R.T.. F.A.A.R.C., .James K. Stoller, M.S., .M.D., F.A.A.R.C. 

The Cleveland Clinic Foundation. Cleveland, Ohio. 

Background: In the conte.xl ot current stretched healthcare provider 
rcsimrecs. strategies to optimize alliKatlon of clinical services are being 
actively explored. To hetter understand the types of respiratory care-related 
activities provided by nurses and the amount of litne alliK-ated to these activi- 
ties, we conducted the current survey. Methods: A questionnaire was admin- 
istered to a convenience sample of 105 nurses at the Cleveland Clinic 
Foundation during their shifts. The questionnaire was administered hy a respi- 
ratory therapist, either by inlerv iew or by nurse sell-administration. We 
recorded the clinical venue (e. g.. intensive care unit or regular nursing tloorl 
and the duration of the nurse's assigned shift (i.e.. 8 or 12 hours). The survey 
asked the nurse to estimate the time in\ olved on an average shift perl'omiing 
the following activities: setting up supplemental oxygen, measuring pulse 
oximetry, administering aerosolized medications, administering all 
medications, instructing the patient regarding incentive spirometi^, perform- 
ing suctioning, pert'orming tracheostomy care, performing 
electrocardiograms, phlebotomy, as well as charting and paper work. The 
questionnaire also surveyed the amount of time taken measuring vital signs, 
inserting and maintaining intravenous lines, maint.iining chest tubes, and 
trans|K)ning patients. Results: Ot the 105 questionnaires administered. 4 were 
excluded because of incomplete data. Fifty-six of the nurses who completed 
fonns were on 8-hour shifts and 45 were on 1 2-hour shifLs. Ninety-one of the 
nurses (909c) surveyed worked on regular nursing floors and 10 worked in an 
inlciisive care unit. Table I presents the mean percent of time on the total shift 
( w hether 8 or 1 2-hour) repi iilcd pcrtiirming some of the commonly 
perfonned respiratory care-related tasks. 

Tahle 1. Results of the Survev 




M eJ s 











Cumulative respiratory cire-related activities were reported to consume 29Tf 
(+ 26) of the nurses' shift time. Conclusions: The results of this survey sug- 
gest that a small but significant amount of nurses' time is allocated to 
performing respiratory care-related activities. In the context of cunrent goals 
to alkx'ate optimal care, this study invites re-examining ways in which respi- 
ratory therapists and nurses can optimally collaborate in prov iding care to 
patients. OF-02-033 


Kathv I'rmelz. RRT . James E. Martin. RRT. Departments of Pulmonary Services 
and Pediatrics, MetroHealth Medical Center. Cleveland. Ohio 

BACKGROUND: The Pulmonary Services Department of our 700+ bed 
academic community hospital is made up of 61 respiratory therapists who belong to 
either an adult core (surgical and medical specialties) or the pediatric core (neonatal 
and pediatric intensive care units, and general pediatric and adull tloors). To allow 
for an equitable time in each area, a two-week rotation schedule within each core 
was initiated. The average time between rotations is 6 to 8 weeks. The pediatric 
rotation includes 22 registered respiratory therapists ( 16 primary and 6 secondary 
who assist the primary therapist) As part of the pediatric core, the Pediatric Inten- 
sive Care Unit IPICUI is unique in that its senses cover a wide range of patient ages 
and acute and chronic illness. To assist their fellow practitioners, a group of 
primary PICU thcr.ipisls put together a PICU Resource Book 1PRB|. The resource 
book IS comprised of patient notes on those who frequent the PICU. detailed 
descnption of equipment set-ups and photographs, calculations for initiating 
continuous and intermiuent medications, and ventilator strategies for different age 
groups and disease states using Ihe five dilferenl types of vcniilatois. METHOD: 
.\ survev was developed lo determine Ihe frequency iherapisls referred to the PRB. 
Ihe sections referred lo most often, and if the availability of the PRB initiated ther- 
apy quicker and added to the therapist's self-eonfidenee when assigned to the 
PICl-I. The survey was placed m the mailboxes of 61 respiratory therapists and 2 
clinical education' specialists. RESULTS: M of the M {5i7r | surveys were 
returned- 2 clinical specialists. LS adull core, and 17 pediatric core therapist 
completed the survey. The pediatric core's results were used for analysis. 17 of the 
22 responded [77'/? j to the survey ( 14 primary. ."^ secondary). 50% of the therapists 
have >5 years experience in the respiratory field, and ^^7f of the primary PICU 
therapists have >5 years experience in the PICLL All of the 17 who responded were 
familiar with the PRB. In a six-month period. Ti''i of the priin.iry therapists 
referred to the PRB occasionally (2-12 limes) while l(K)9i of the secondary PICU 
therapist referred lo it inlrequenlly l<2 tunes). The Clinical Education Specialists 
also used Ihe PRB .is one ol llicir tools for familiari/ing students and onentating 
new therapists to the unit ^l^i of the primary therapists referred to the patient 
notes and equipment set-up most frequently, followed by photographs of equipment 
set-ups and calculations while lOO'/r of the secondary therapists referred most fre- 
quently lo set-ups and photographs. All Iherapisls believe that the availability of 
the PRB made Ihem more self-rclianl. ^4'; believe the book added to their self- 
confidence in the unit and iiKuie them more elficienl 7791 believe the PRB assisted 
them in initiating therapy quicker. All of PICU therapists wouki like to see the 
same type of resource book in other ICU areas. CONCLUSION: Respiratory ther- 
apists routinely assigned for a two-week rotation in Pediatric ICU areas could bene- 
fit from putting together a resource book specific to that ;irea The availability of 
this book could make them more efficient and self reliant when assigned to the 
^r--'^- OF-02-037 

Raymond Mallov BS RRT . Thomas Jefferson University Hospital, 
Philadelphia PA 

BACKROUND: Recently in the Respiratory Care Depanment .at Thomas 
Jefferson University Hospital, there was a large turnover rate due to com- 
petitive salaries in Philadelphia where respiratory therapists are in high 
demand. The cost associated with a high turnover rate is approximately 
$15, 000.00 per employee secondary to advertisement, recruitment, sign- 
on bonuses, relocation expenses, employee physicals, hospital 
orientation, departmental training, and overtime staffing, agency and 
travel expenses during our six week orientation period. In a twelve 
month period 16 full time employees (FTEsI resigned out of 46 FTEs 
059, ) for Respiratory Care, at a cost of approximately $240,000.00 We 
also were expanding our critical care services and were given an 
additional 5 FTEs. METHOD: A salary survey was done and the respira- 
tory therapists were found to be 8%- 1 29c under the median range for the 
Philadelphia area. A salary adjustment was completed Ihe following year 
at a cost of $199,000.00 to increase the annual budget. 



Turnover Rate: 

16/46 (.^5%) 
6/5 1 ( 1 29c) 



CONCLUSION: There has been a decrease in turnover cost to the hospi- 
tal of over $ 1 50,000.00. The respiratory department's salary increase of 
$199,0(X1.00 will see a positive return after 1 year while maintaining sig- 
nificantly lower turnover rates. 


I 0.54 


Sunday, OCTOBHR 6. 12:3()-2:2.s pm (Rooms 20-21) 

Hhc- Rmhcrtoni . HtMlhcr Avicivr. Ntclivvi Overton. AS. RRT. Respir.iU)r\ l^hcnipy l*n>};nini Indiana 
L'nivtfrsil) . Rkhual ConniLan. US. RRT. Clahan Heailh. Lintb Van Sctxlcr. VAD. RRT. Asstxialc Pnv 
k-^MU, R(.-spiralor> ITxTapv IVijiram. Indi;inii I'nivcrsil). 

Back}>nHind: SliKiic>ha\c>ihowTibctlcralIocalii>nol'ix.*spiratcir> ^c^\il.■c^ wlu-n therapist ilnvcn pn«li>- 
atlN lT[)Ps I wcR- iistti Other dcnionMralcil hciK-tlb. oC TI51\ arc siandiuxli/cd medical practices. Umer 
cosLs and inipm\ ed quahty ot lile wiUutut causing adverse clTcct,s This study was coniplclfd fvtrx>sp«.v- 
tivelv with the puqxtse of delcniiuiinj: illhe implenieiilation ol'non-K'U respiratory TDPsat a kirge. 
niid-wCNlem hospital had the c\ixvtei.i heiiet'its ol' more optimum allivation of ta\itntent nuKlalilies and 
moiv adequate follow -up rciussessiiK-nl lor the motlalities nnlered. MelhiHls: A comrol group (5.^ I anil 
an e\fvnnK,'ntaf i;n>up 1 51)) ot persons at le;ist I S years of age uhn avcived aenisol therapy w ith hron- 
chixJilatorN or vasivonsinclors, volumes expansion therapy or brvmehiv-pulmonary hygiene by respira- 
tory tlierapislsiRTsiinanon-lCl' seltnig and who werv not ucatedby apulnwnologist, Tliccomml 
group uas cho^en fn^ii the year prior to miplement;ition of ihe patient avsessment pn>gram (TDPs). and 
the evpeniiKntal ginuip fr>im the pentxl that the assessment pmgram has been in use. The subjects were 
seltxiedhy sysicnuuic randomi/ation. Ilie medica! a'cords werv rvvicwcd todelenniiie it proper indica- 
tions existed for the therap> and it follow -up rv.issessmeni of the therapy (vcurred within 72 hours ol the 
onler To establish inlcr-ratcr ivliabihiy. the ^ c\aUiatorv inuially rvvievved the vune S nx'oals ;ind made 
identical conclusions by following Cleveland Clinic's a'spiralory treatment algorithms, which are based 
on the Ainenc;m Association for Respinitory Can; I AARC) Clinical l*niclice Guidelines (CPGs). Tlic 
chi-squared lest was used to detemiine whether the grtiups had a significantly dilTcrcnt incidence of 
prvtpcr indication ;ind whether (he gn>ups hiid a signiUcantly dilTertnt uicidence ol lollo« -up assessment 
within 72 hours Resiilk: The peaent of overall lhcrap\ that met proper indications with TDPs was not 
sigmllcantly impnued over phy sician ordered therapy Appa>priaieness of therapy for bitinchtxJilators 
was belter \s ith TI^Ps than w hen phy sician ordered but for iS. physician ordered therapy showed a higher 
rate of meeCing paiper indications A signiticani imprtn emcnt in follow-up assessment was 
dcmtmslratcd with TDPs. 

Protocol Indications and Follow -up .Assessment 

overaH indications 


IS indications 

















1 N=47 1 











nol mcl 









'( mcl 



57' r 




h(V r 

90' r 

p \alUL' 





Conclusions: I'he outcome of this study divs nol demonstrate a signitlcant dillerence between the 
.ippn>pnjk'nes'' iifrcspirjliipi therapy when ordcad hy a physician 1 75'^( ) and when guided by RTs 
(?'•' r I hut It does shou that RTs were at leasi as succcsstul as ph\siciansat ensunng that pmper indica- 
tions existed In addition, follow -up assc-smenl signilleanlly impnned vshen pertbmied by RTs (W.'; ) 
comparted to follow-up by physicians ibfy^i |. This is signiticani because trealmcnt given when no longer 
indicated adds unnecessary costs to an already overburdened healthcare budget. Therefore, the 
implementation of the respiratory patient as^^essmenl pnigram was demonstrated to be benefici;U 


RRT and Jem R. Kirsch RRT. Respiratory Care Services (RCS). Nebraska Health Systems, 
Omaha. Nebraska. 
The henericial effects of having a Respiratory Care Practitioner (RCP) play a role in the Emer- 
gency Department (hDi has been diKumented iii the literature However, a lack of information in 
the literature evists in trialing RCl's stalling in the liD 24 hours/7 days a week while expanding 
their role and assessing subsequent impact We conducted a trial from Nov 14. 2(MII through 
Dec 2l.2tMH During the trial an RCP siafled in the HD 7 days a week liom 7a, m until 
7p,ni and collected the lollnwing iiifonnatioii patient name, medical record number, triage time, 
irealment start lime. Shortness of Ha'alh iSOBi Pathway ulili/ed ( Y/Nt. education pro\ided. 
patient admitted or discharged, time admiiled or discharged and priK-edures performed. The 
triage time was compared to Ihe treatment start time to assess response lime. During the time a 
RCP was staffed in the ED. the mean response time to treatment given was 12 5minules imean + 
12 minutes SD) with a range otl)45 minutes The mean res[>oiise lime during non-lrial times in 
the r.D |7 pin until 7 a.m. I was 27 b minutes 1 16 minutes SD) with a range of .S-70 minutes In 
these latter cases the RCP was notified when the patient was assessed and detennined to need a 
treatment. Patients assessed by RCS during the trial and presenting with shortness of breath (4.1 
patients) were placed on the SOB Pathway for treatment. Additionally, the majority of these 
same patients (35 patients) received education regarding their shortness of breath, disease man- 
agement and medication regime. Eleven additional patients that were not placed on the SOB 
I'ailiw.LN but detennined to ha\e a history of pulmonary disease received disease management 
ediicjtion, Ol these patients receiving education, the majority stated they had not received previ- 
ous education in arlalion to disease management (Jf specific iniea'st. three patients seen during 
non-lrial hours were in the ED at least tw ice ilunng the same 24-hour period, When these reium 
\ isits occurred during the RCP trial hours, education was provided and the patients did not return 
to the ED Included in Ihe education component was a follow-up call to ihose non-admitted 
patients 24-48 hours after discharge lo the ED The purpose of the call was to answer any ques- 
tions the patient might have and to reinforce any education Of the patients seen in the ED during 
nontnal hours, none were placed on the SOB Pathway. Of these 2^ patients qualifying, only two 
received education regarding their shortness of breath, disease management and medication 
regime- During the trial 77*^ of the patients with pulmonary disease and treated by RCS were 
discharged from the ED: the remaining 23*^ were admiiled. During non-trail hours only 52*7^ of 
the palient.s with pulmonary disease were discharged from the ED with the remaining 48'^ 
admitted. It also appears that from the data those patients treated during the trial had fewer 
aerosol treatments given prior to admission (average 2.2 treatments), than those admitted during 
non-trial hours (average 4. 1 treatments). Addilionaliy. the data noted the average lime spent in 
the ED before discharge or admission was 18."^ minutes (107 nnnutes SDl lor lhi>sc palients seen 
dunng non-lrial hours versus 136 minutes (+72 minutes SDl for those patients seen during trial 
hours In summary . RCPs role in the ED would provide enhanced patient care to those patients 
treated in the ED, The patients in the ED dunng trial hours were either admitted or discharged 
sooner than those non-trial patients This could have potential financial impact on the ED as vol- 
umes could increase with patients moving tiut of the ED sooner, Palienls during trial hours were 
responded lo sooner than palients during non-lnal hours. This could have Impact on patients 
admit or discharge limes. Those non-lnal patients also received more aerosol treatments, w hich 
could mean Ihese patients received non-indicated treatments In i.onclusion. the results ol this 
tnal indicate that RCPs have a significant role in the ED in improving patient care and poicniial 

patient outcomes 


SL'RG lAITS - Scott Thomas RRT . Thertsa Bergquisi RRT. TixJd Smith BS RRT. 
Deb Ryan CCRN. JoAnn Munski RN. Rand;tl Baker MD. BmceBonnell MD. James 
Hoogeboom DO, Spectrum Health. Grand Rapids. Michigan. 
Background The Adult Cntical Care QA data at our hospital ivvcaled a problem with 
unscheduled returns of trach patients to the ACC units, in researching this topic we found 
several factorx that contnbuted to these returns to the unit. Trach follow up w u-i inconsis- 
tent once the pabent left the ICL". variation ol practice regarding downsizing, capping and 
decannulaiion and a general lack of knowledge of who is r^spoasible for the trach care. 
Methods A Trach Team consisting of RRT's and RN's was created with support of 
ph\ sicians. The goals of the team were as follows: 

Develop standardized guidelines for downsizing and decannulation of (ntcheoslom\ 

StiindunJized the tracheostomy tubes to be used in the hopital. 
Develop a custom trach care kit. 
De\ elop standing orders for the care of tracheostomies. 
Revise the Policy and Procedures regarding tracheostomies. 
Clarif) the responsible ph\ sician when the patient has left the ICU 
Camy out stafi" education on all the changes and procedures. 

Results: There have been NO unscheduled returns lo the ,Aduli ICf's since the start of 
the Irach team. Once the ftvus of the trach team was to facilitate downsizing and 
decannulation. 50'"^ of patients had their trachs dow nsi/ed and MV' were decannulaled 
pnnr to transfer or disch;irge, Forthedecannulated patient, the average lime from off 
positive pressure to decannulation w:ls 7.5 days. Trach Length ot Stay has decreased 
trom 26 Iti 1 6 day s after the Trach Team was developed. 

{■ Hrfon Tnch Tna 

Cunclasions: The Trach Team has achiev ed all of its initial goals. 'Iliis resulted in 
improved patient care and patient s;itisfaclion along with cost savings for the hospital by 
eliminating the unscheduled returns of patients to the ICU due to tnichesotomy issues, 



Edwarxi Conwav. RRT Man Pat Alfaro, M.S.. Ha^T^' Atherton. MS,. P;miela Schoettker. M.S.. 

Kale Turck. BS. 

Cincinnati Children's Hospital Medical Center, Cincinnati. Ohio 

Background Bronchiolitis, an acute illness affecting young children, involves inflammation nl 
ilic lower airways, making breathing difficult. The rouline use of bnmchodilaior therapy contin- 
ues to be a common treatment for these patients even though the ev idence supports irealnienl 
onK if It results in documented clinical improvement ' ' Therapies shown to Iv effective include 
suctioning and maintaining hvdralion ' Part of ourcommitinenl to pursuing |XTleclion in health 
care includes reducing the unnecess.irv useof bRinch(.>dilatt)rN For fiscal vear 2'X)2. our 
ev idence-based clinical practice guideline for acute bronchiolitis w as rev ised to encourage the 
use ol n:spiratory function assessment to detemiine ihe need for and effect of bronchodilaior 

Methods , The revised guideline was implemented November 2S. 2001. li recommended nasal 
suctioning and immediate assessment of respiratory function by respirator, therapists before 
and after the suctioning, prior to a trial treatment with a bmnchtxiilator. Respiratory function 
was assessed via a respiratory score that included consideration of respiratory rate, accessor> 
muscle use. retractions, wheezing, and 1:E ratio. H the posl-suetioning score showed a dramatic 
improvement in respiratory function, ihe bronchodilator therapv was not reconimended, If a 
broiiLhiKliLitor treaimeni were given, respiratory scores are obiaincti hclnre and ?() minutes alter 
Its admiiiisiratii)n. The guideline recommended that no tunhcr hroiKliixJilalors be given it no 
positive resp*>nse Ui Ircatnicnt was d(n.umentcd 

Patients admitted vmiIi a diagnosis ol acute bronchiolitis and no other medical historv 
were eligible for the bronchiolitis guideline The number and Irequency of bn>nchodilaior treat- 
ments lt>r patients admiUed between \2Ji)\/H)()l and 3/31/2002 were compared to palients 
admitted dunna the same time period ot the previous bnmchiolitis season i 12/01/fHI- 

Results Following implementation of the revised guideline, the pmportion of patients receiv ing 
anv bmnchodilaior treatment decreased from 6 1 9r io57^(- Patients receiving only one trial of a 
bronchixiilator treatment increased slightly from 24*^; to 289f , The proportion of patients w ho 
received more than one bronchodilator treatment decre*ased significantly from M'^/i loMVf ip = 
0.01 1 and the mean number of Ire-alments decreased from 3,7 to 2,5 ip = 0.03), When consider- 
ing onlv palients who received broiichtxlilators. the mean number of doses decreased from 6.0 

Conclusion The ase of the rcspiratorv assessment score had a significant impact on the 
fa'quencv iuid intensiiv of bronchixiilator treatments. The role of the respiratorv therapist w as 
critical in the decision-making priKcvs. 

I . Rores G. Horwitz Rl, Efticacv of beta2-agonists in bronchiolitis: a reappraisal and meta- 
analysis. Pfduirricv IW?; irK):233-23** 

Kellner JD. Ohisson A. Gadomski AM. Wang EE. Efficacy of bronchcxlilalor therapv in 
bronchiolitis. A meta-analvsis. Arch PetliairAiloU-sc Mi-d. 1996J50:I I66-1 172, 
Luuo RA. Salver JW. Dean JM, Albuterol in acute bronchiolitis — conlinued therapv despite 
pinV response'" \^m 108-202 

Klassen TP, Recent advances in the treatment of bronchiolilis and laryncitis. PcJiurrClin 
^I,>rthAm I W7: 44:249- 2M 


Respiratory Care • September 2002 Vol 47 No 9 


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Tel (800) 446-3908 l^x (949) 470-3933 Email Web 

Sunday, October 6, 3:00^:5? pm (Rooms 18-19) 

The EtTccis of Inservice Education and Annual Performance Reviews 

on the Comphcations of Nasal CPAP in the Neonate 
Kathleen Deakins RRT . Steven Clark RRT. and Timothy Myers BS RRT. 
Rambow Babies &. Children's Hospital. Cleveland. Ohio 

IntrtKJuction: Nasal CPAP (NCPAP) is used to reduce ainvay resistance and work 
of breathing, and improve oxygenation and compliance through alveolar slabili/a- 
lion in the treatment of newborn Respirator^' Distress Syndrome. Along with these 
physiologic benefits of CPAP is the potential for ctMiiplieation devL-lopment caused 
bv improper application and maintenance of the CI'AP dc\ ice The purpose of this 
observational study is to detennine if annual staff inscr\ ice education and training 
affects the number of CPAP complications in our neon.ilal population. Methods: In 
a pnor observational study conducted November 20tK) to May -IK) I. we 
dtKumented the incidence of complications incurred dunng NCPAP delivery at 
347(. When utilizing fluidic NCPAP. we documented a complication rate of 4l'7f . 
With conventional NCPAP, I59f of our patients developed a complication. Nurses 
and respiratory therapists share the responsibility of maintaining nasal CPAP in the 
NICU. Annual performance reviews for NICU nurses (- l.'^O) included completion 
of a self learning packel including a review article on CPAP. review of indications, 
complications, ways lo prevent scplal breakdown, and causes of weaning fail- 
ures from CPAP. A pt^st-tesi was given at the completion of the review. In May 
2()01. a Clinical from Hamilton Medical provided inservice education and 
training to nurses and respiratory therapists. At the conclusion of the rev iew period, 
the obsx'rvaiional study was repeated. From May ^ 1 . 2001 to January 2. 2002. 100 
patients received NCPAP m our NICU. The Infant Star ventilator provided conven- 
tional NCPAP. NCPAP prongs (Medicomp Inc. Pnnceton MN) were secured by 
twill tape attached to an Arabella NCPAP cap. Fluidic NCPAP was delivered by 
the Arabella NCPAP system (Hamilton Medical. Reno NV), An Arabella NCPAP 
cap secured lluidic NCPAP prongs and generators. We assessed patients on a daily 
basis for complications caused bv NCP.\P. Complications assessed included bleed- 
ing, flaring ot the nares, nasal septal breakdovv n, orbital edema and excoriation ot 
the nares. ^Results: In this follow-up study. 22*7 of all patients placed on NCPAP 
developed at least one complication. Eight percent of patients on conventional and 
3 1 1- ot patients on fluidic NCPAP de\ eloped complications. The table compares 
complication rates before and after annual rev lews and inservices: 

Total # patients 

VVeieht/Ge-st.Age Year Incidence of Complications % change 


Con%entional CPAP 




Fluidic CPAP 





Conclusion: Overall, we realized a ?>59c reduction in our NCPAP complication rate. A 
greater reduction ctcurred in conventional NCPAP compared to fluidic NCPAP. 
,-\nnual performance rev iews with education and training contributed to a 
reduction in the incidence of NCPAP complications in our NICU. 




Teresa A Volsko. BS. RR T. FAARC. Robert L Chatbum BS. RRT. FAARC, 

Sally Lambert, PhD. RN. Michael W Konstan MD 

University Hospitals of Cleveland. Case Western Reserve University 

OBJECTIVE: To evaluate disease management of cystic fibrosis (CI) in pcdiatnc 
patients using a care manager and a standardized care path (CP) Outcome variables 
were hospital length of stay, quality (completed airway clearance therapies, completed 
nutrition assessments, readmission due to failed home uitravenous antibiotic use) and 
elTiciencv (delav of miUal intravenous antibiotic administration, home IV antibiotic 
use) METHODS: Our interdisciplinarv learn developed a care path for the treatment 
of an acute pulmonary exacerbation which included practice guidelinefi for niilniion 
evaluation and support, airway clearance regimens, and orders for laboratory and 
diagnostic tests This study was compnscd of I? I consecutive patients. < 1 8 years of 
age that were admitted to Rainbow Babies and Children's Hospital for treatment of an 
acute pulmonary exacerbation of CF between Januarv I, 20{)U and December 31. 2(KI| 
All patients were treated accordmg to the standardized care path Baseline length of 
stay data, mean antibiotic time lo administration, and home IV antibiotic use were 
obtained from a retrospective review of all C"F related hospitalizations from January I 
to Dceciiibci 31,1 9*>*> Paiienls admitted for reasons other than an acute pulmonary 
exacerbation were excluded along with those with significant co-morbidities Pre-care 
path data specific to missed nutniion evaluations and missed airway clearance 
treatments were obtamed from chart review of a matched sample of patients, identified 
in the baseline group, to diose analyzed ui the post implementation group, admitted 
from November 12 lo December 31, l**99 Data were analyzed with Mann-\Vhitncy 
Rank Sum tests and Chi-Squarc tests RESULTS: Outcome data m percent or mean 
values (+ SD) arc shown in the table below (pre and post care path implementation) 

Number in study 

Hospital LOS (days) 

Home IV antibiotic use (%) 

Missed respiratory trcaimcnts (%) 

Missed nutnuon cvaluauons (%) 

Delay of aniibiolic admmisiralion (hours) 

Failed home IV antibiotic therapv (%) 

Pre care path data for home IV antibiotic rate were not available The pwwcr for the 
test of nutntion evaluations was only (t.23 CONCLl'SIONS: Active disease 
management of cystic fibrosis, usmg a care manager and a standardized care path, 
decieased length of stay and improved both quality and efficiency outcomes 







N.I) (6 8) 









35 7 






Not available 




Calvin Clark. RRT RCP . Barbara Prieur RRT RCP. Ann Ramirez RN, 

Donna Cravener RN. Brian Wood MD. 

Mission-St. Joseph's Hospital. Asheville, North Carolina 

Revievs' of our outcome data demonslraled that the incidence of chronic 
lung disease (supplemental oxygen requirement at 36 weeks adjusted 
age) in infants with birth weights of less than or equal to 1500 grams 
cared tor in our nursery was greater than that ot our benchmark, the Ver- 
mont-Oxford Network. There are certain care practices that cause lung 
injury and are associated with an increased risk of developing chronic 
lung disease. We evaluated our practices, reviewed the medical 
literature, and developed a delivery room management strategy founded 
on evidence based medicine geared toward minimizing lung injury in the 
immediate postpartum period. These delivery room changes included the 
administration of Curosurf'^' (poractanl alpha), a porcine lung 
surfactant, within the first 5 minutes of life, the use of the Fisher & 
Paykel Neopuff ^^' Infant Resuscitator to minimize over distention of the 
premature lung and maintain functional residual capacity with 
continuous positive airway pressure, and the use of oxygen blenders and 
saturation monitors in L&D and on the transport incubators to facilitate 
weaning of oxygen. During the first seven months of 2001 the incidence 
of our chronic lung disease was 589^ (n=45). FoHowing the institution of 
our new delivery room practice, the incidence of chronic lung disease 
during the last five months of 200ldropped to 30^7f (n=48}. In addition 
to the improvement in our outcomes of chronic lung disease, other bene- 
fits were also apparent, such as the proportion of infants discharged from 
the hospital on supplemental oxygen decreased from 40^/f lo 12'7r. and 
the average time on inechanical ventilation decreased from 21 days to 1 1 
days. We feel that by comparing our outcomes to benchmark institutions 
we have improved our standard of care and the quality of life for our low 
birth weight infants. 


UNIT: A QUALITY INDICATOR. Brendak.BjCls. M. PH..RRT . Hughes Spalding Childrcns Hos- 
pital. James McCrory. MD Pcdiatm.- Cnncal Care. Morehouse SLhi>(>l of Medicine. Hughes Spalding 
Children's Hospital. Ann George. M.H A , Quality Uiili/alion Spei.ialist.Grad> Health System 

INTRODUCTION: Accidental exlubalions may lead to complications in critically ill infants and chil- 
dren on mechanical ventilator\' support- These complications can cause increase morbidity and mortal- 
ity Many factors contrihule lo unplanned extubations in the pediatnc population Currently we track ail 
unplanned cxtubauons as measured hy the total number of unplanned exiubations relative lo the lotal 
number of ventilator days The national benchmark for this indicaior is<5'^( Forlhe kist year, the range 
in our Pediatnc Unit is 1 5*/f to 2 (Kt TTiis is being monitored because it has high nsk iniphcations that 
could result in death. This indicator is also problem prone and can increase the cn>.i of the patient care 
due 10 increM.sed length of stay METHODS We used the FOCI'S- PDCA meUi.)dol..g> We fir^t 
organi/ed a multi disciplinary team of siaff members uhu kneu the priK.-ess Members included: respi- 
ralor>' therapy staff and super^■lso^, nursing staff, physkians and niialily rnanagerncnt staff. After clarifi- 
cation ot current knowledge and collection of infomialion. wc idenlified sources M prcxess vanations. 
Team members then planned the imprt>vemenl, implemented the plan and began to collect (he data. The 
PICU quality assurance monilonng form lor unplanned e\luhatn>ns wa.s used for continuous data col- 
lection and evaluation. Data collected included: ( 1 1 Time and place of the event, i 2 ) Htiw and who dis- 
covered'!' ( 3) Patient's LOC. events preceding extubation. ( 4) Did patient develop problems and need 





Was Etribe Securely Taped? 

Were Restraints Used? 

Did patients reqiire 




_=S0'5t by R.T, sialT, 
=50^ by nursing staff. 

2/2=100% were securely taped. 

_=50% were restrained 

2/2=\00^ required remtubation 

A Unobserved 

B Palieni lumed head 

C Agitated and lighling 

D Vomiled and grabbed lube 


Educate staff and 
increase awareness 
Develop strategics 
to impnive i)Ulcomes 

Continue to monitor 
and document all 

unpUiniied exiuhaiion' 

Review findings \Mih 

Re\iew a-slrainl 
pn>kKol wuh slah 

Remlubaled secondary 
bradycanlia. and pain 

Re\iev, findings With 
respiratory . nursing 
and physician slaJT. 

CONCLUSIONS We conclude thai the level of restraint use. pnvedures. and tube fixatton conmbuled 
to the incidences of accidental cxtubauons m mlanLs and children. Moreover, monitonng of unplanned 
extubation occurrences should he an ongoing qualilv indieaior in pediatric mlensivecare uniLs. Wc will 
conlinuc lo monitor and documeni all unphuined evtubalions 


Respiratory Care • September 2002 Vol 47 No 9 


Sunday, October 6, 3:00-4:55 pm (Rooms 18-19) 


Robert J. Roancss. RRT. CPFT . Jamie Clink. BS. RRT. RN. Michael Trevino. MS. 
RRT. Gar> Wcinslein. MD. FCCP. Thomas Pullano. MD. Presbyterian Hospital of 
Dallas. Dallas. Texas. 

Introduction: Nitric oxide (NO) therapy is used in neonatal intensive care to treat 
Persistent Pulmonary Hypertension of the Newborn (PPHN). Toxicity of inhaled 
NO is extremely low when administered appropriately. However, even at normal 
clinical dose* (lOO purls per million), careful monitoring of the effects of NO is 
ncccssan. to ensure the safet\ of the patient. Rare cases of methemoglobinemia 
ha\ e been reported as a result ol NO therapy. It is the practice of our institution to 
routinely measure methemoglobin (metHb) in infants on NO therapy. 

Case Summar>': Two term infants in the Neonatal Intensive Care Unit (NICU) 
were receiving NO therapy at 20 PPM. initially with metHb levels of \-29c. Over 
the next few days, both of their metHb levels steadily increased to 8-9*!^ despite 
improvement in clinical status. Pulmonary laboratory staff was called to verify the 
accuracy of the analyzer, an Instrumentation Laboratories ilLi 4SI! CO-Oximeter. 
Pre\entive maintenance was performed, and three levels of controls were run with 
results in range. New blood samples were obtained and analyzed, but melHb levels 
remained >5^. Technical support at IL was called for further direction; however, 
even after further diagnostic troubleshooting, the machine appeared to be in work- 
ing order. Pulmonary laboratory staff still suspected that the results were incorrect, 
and therefore asked IL to send a field technician to inspect the machine. After IL 
performed annual preventive maintenance and three levels of controls were run. 
blood was again analyzed for melHb. The results were still >59c. This time 
however, the specimens were saved and analyzed on an IL 482 at a different facil- 
ity. The metHb levels in these specimens were normal. IL was asked how the two 
machines could be measuring the two samples so differently. Further investigation 
revealed that the analyzer's hemolyzer was not functioning properly, resulting in 
inaccurate metHb measurements despite normal controls. 

Discussion: Quality control materials are used to validate the accuracy and preci- 
sion of an analyzer. In this situation however, the machine was giving erroneous 
information despite acceptable control values. On the IL 482. as well as the IL 382 
and IL 682 CO-Oximeters. there is no alarm to alert the user that the hemolyzer is 
not functioning properly. Since the controls were already hemolyzed. expected val- 
ues were normal, while whole blood samples were being measured incorrectly. 
Potentially, this could be a serious problem for the treatment of any patient 
whose management is being guided by the metHb results produced by this series of 
CO-Oximeter. While these machines are no longer in production, hundreds are still 
in use nationwide. Clinicians should be aware that verification of machine accuracy 
in this IL CO-Oximeter series is not necessarily confirmed by 
acceptable qualilv control. OF-02-1 18 

Case Report: Proactive Invasive Pulmonary Function Testing for Surgical Inlen en- 
tion in a Barnes Svndrome Patient: Timoth\ Co\. RRT. Thomas Blackson. RR 1 . 
ThcMiKL^ Shatter. PhD. David Paul.. MD. Kem. Wcis. MD : A 1. duPoni HiTspiuJ l..[ 
Children. W ilnimgion. De. Christiana Can: Health System. Newark. De.: St. Peters Hosp.. 
New Brunswick . N.J. 

Introduction: Biimes Syndrome and Jeune asphyxiating thoracic dystrophy are rare, com- 
plicalcd. syndromes, that when symptomatic, can result in significant ventilator) impair- 
meni in the altcdcd ne\'.bom Wc report a case in which pulmonary mechanics mcasure- 
menLs. utilizing L-sophagea! manometry . were utilized to determine the rclaUve conlnhututn 
of the chest wall and lung to the decrease in total thoracic compliance expenenced h> a 
newbom with Barnes Syndrome, The results of the pulmonary evaluation were uuli/ed to 
assist in establishing acceptable ventilator settings as well as to serve as a pre-surgical 
screening tool pnor to consideration of lateral thoracic expansion. 

Case Report: The infant was a full temi. day 36. female weighing 3.2 kg. She was bom 
with obvious thi>r.icic d\ slrupliy. and was hreathing through a 3,5mm ID tracheostomy tube 
with mechanical \cniilaion .t'^sistancc at the time ul the e\aluation. The ventilator \vas set 
to deliver PCV \cntilaiion. IMV RR 40/ mm.. PIP: 26 cm H:0. PEEP: 7 cm H;0. T|: 0.4 
sec FIOi: 0,4 The patient was instmmented with a 6fr, esophageal pressure monitonng 
catheter and a differentia] pressure transtlucer at the airway. ( PEDS system. MAS inc.. Hat- 
field. PA), for data collection. Results: 


Predicted Normal 

Test Results 

Percent Predicted 

Compliance Total 

0.8- 1,3 ml/ cm H^O/kir 

224 ml/cm H:0/kg 


Compliance. Lung 


fl 24 ml/cm H^U/kg 


Compliance. Chest Wall 

4.2 ml/cm ll^O/ki: 

: 7 mlvm H:()^'kg 


Resistance. Total 


1 ^S Sc-m H-()/ljscc 

397' ^r 

Resistance, insp. 

29 -40 cm H^()/l7-<-L 



Resistance, exp. 





24-30 ml/ks 

10,1 mi/ke 






Discussion: These findings indicate that the chest wall and lungs were contributing to the 
decrease in total compliance in this infant. In addition, the elevation in pulmonar. resis- 
tance may appear secondary to the \ov, FRC. Based on this data, the ventilatory manage- 
ment plan was directed towards reducing PIP ventilator) suppiirt. increasing PEEP for FRC 
management, and einphasi/ing chest wall stabilization to allow growth and mamration. 
Clinical Implications/Prognosis: Surgical intervention through the use of lateral thoracic 
expansion is a safe and effective procedure for infants with asphyxiating thoracic dystro- 
phy. It IS most commonly indicated alter the first yc;ir oi life. Initial management of 
patients includes a lung protective strateg) aimed at acceptable \enulation while anempnng 
to avoid further respiratory damage from mechanical ventilation. This case demonstrates 
the use of advanced pro-active pulmonary function assessment m the early stabilization and 
management of a patient destined to require long term respiratory care. Finally, serial pul- 
monary function studies may be warranted following surgerv . 

OF-02-1 24 

Hartling RRT. Karen Baldcsare-Burton RN. RRT. Catherine Nelson RN. CCM. 
Primary Children's Medical Center. Salt Lake City, Utah. Background: Increasing 
numbers of pediatric tracheostomy (trach) pts are making the transition from the 
acute care setting to homes and extended care facilities (ECF). However, sending 
these pts home can increase their risk of injury or death from accidental decannula- 
lion. The level of care required outside the acute care hospital, e.g. ECF, home care 
or continuous in-home nursing care ought to be based, in part, on the risk of injury 
from decannulation. Therefore, we sought to develop an instrument that would 
quantify this risk. Methods and Results: An expert panel was formed that included 
RT's, MD's & RN's. They identified 8 dimensions of risk of injury from decannu- 
lation. each of which is to be scored at one of three levels (except the age of the 
trach, which is scored on two levels). Definitions for each dimension were 
developed. The score was tested on 25 medical records. Results indicated that 
additional refinement of the definitions was required, which was done. The table 
below lists the dimensions of risk and their definitions. A score of 1 through 23 is 
possible, with the higher score indicating higher risk. 

Dimensions ol Kisk 

Score 1 

Score 2 

Score 3 

^gc ol U-ach 

> SIX weeks 

< six weeks 

Tritdi dependency 

Can pass air through 
ihc upper airway 

Can pass air 
through the upper 
airway difficulty 

Can pass no air 
through upper 

Cugniiive abtliiy: us 
jenainmg to irach care 

Able lo learn and 
care fur^elf 

Able to leam but 
ni>l able to care 
lor self 

Unable lo learn 
or care for self 








Ventilator assisted 

\ ciUiLiiot Llc|->endent 

Oxygen needs 


Can mamiain 
Sadv >8S^r on RA 

Cannot maintain 
Satt^ >'S8<:i on RA 

Secretion mobilization 

Can identify and 
mobilize secretions 

Can identify the need 
to mobilize secretions, 
hut needs a.ssistance 
in sui.tion or ct>ugh 

Cannot identify need, 
requires assistance lo 
mobilize secretions. 

itisk fur decunnul;ition 

Minimal risk 



Co- Disease 



Life threatening 

Speculation: Higher risk pLs should require more intervention after discharge, e.g. 
extended care versus home care. Interventions like the need for in-home nursing care 
by RNs" versus I.PN's or others ct>uld be determined by the stratification of these 
patients into risk groups. Future research involves determining score accuracy by con- 
ducting inter-rater reliability studies and content validation by studying the 
relationship of this score to the post-discharge incidence of post -discharge decannula- 
tion and any resultant injuries. Wc plan to conduct these investigations. OF-02-1 27 

D. Acton. MD. William D. Hardie. MD, 

Cincinnati Children's Hospital Medical Center (CCHMCl. Cincinnati. Ohio. 
Introduction: Pulmonary Function Tests iPFTsi are impoaani diagnostic tools and out- 
come measures for management. Absolute measures are standardized by conver- 
sion to percent -predicted values to account for growth in children. The accuracy and 
validity of a percent -predicted value depends on the reference equation used, and its abil- 
ity to compare an individual to the appropriate reference population. Inappropriate refer- 
ence equations can lead to diagnostic errors and flawed investigative conclusions. We 
obser\ed that the calculated percent-predicted values for the youngest and shortest 
children did not correlate well with their clinical pulmonar) status or the shape of their 
Oow-volume cur\e. We sought to identify and implement the most accurate reference 
equations available based on current scientific e\ idence. 

Methods: We surveyed a sample of U.S. pediatnc and adult hospitals to identify the most 
frequently used reference equations and conducted a scientific literature review related to 
adult and pediatnc spirometry reference sets. .After completing the survey and the litera- 
ture rev iew. reference sets were established based on age and race. We studied spirometry 
in 1 2 Caucasian males ages six to eight under 1 20 cms in height pertormed at CCHMC 
using the reference equation of Weng-Levinson. We converted the same lest data to the 
reference equations of Wang, Dockery. et al using the same demographic and test dale 
information for each patient. 

Results: Significant differences in spirometry were noted in the percent -predicted 
variables between Weng-Levinson and Wang. Dockery. et al with the largest variations 
being seen in the FEVI parameters. 

Patient HEIGHT 


W ang, Dockery et al. 


































1 16 


















P value < 0.0001 Conclusion: Significant vanability occurs between reference equa- 
tions for predicted v alues fi>r pediatnc spirometry . Variability can also occur in equation 
entry between manufacturers. It is inip(.)rtant to establish reference equations that are evi- 
dence-based, obtained from large sample populations and segmenied on the basis of race, 
eender. heicht and ace. 

OF-02-1 29 


Respiratory Care •September 2002 Vol 47 No 9 

Sunday, October 6, 3:00-4:55 pm (Rooms 18-19) 


TKSTING IN THE NH( )N ATAL ICV Kathc nnc L, I cJorCPrT. RRT (■|c\eland 
Clinic Foundation, The C"liilda*n's Hospital. C'lc\claiid. Ohio. 

Background: I( is not uncommon for kispituls to utili/c unit based point ol care test- 
ing ( P(XT) to gain \ aluablc clinical laboratory' infomiation as quickly and efficiently 
as possible. We wanted to evaluate the accuracy of the total bilirubin rvnient 
a\ ailable thmugh \\ hole bUxxi unit based testing and the impact o\' the R'duced bitxxi 
loss. A re\iew of the hteratua* siongK suggested that ihca* aa- large vanations in biliru 
bin rcsulLs fmin one analy/er to another making nicaningtul c\ alualions difficult. Some 
tactors thutc;in poientiall> alter the hilinihiii results arc fetal licmoglohin. [in.-sencc ol 
RBC" in tlie plasma. henioK Ms of tlic sample, ilic jckI base M.ilus ol the patieiil, and the 
time inter\al from saiiipling to analysis, \\hole bkKKl analysis usuig the .Mil. !}?> can 
factor in the acid-base status of the patient as well as the presence of fetal hcmogobin. 
Methods: Specifically we evaluated the total bilirubin measurements included in all 
routine blood gas samples using the Radiometer 735 bUxKi gas analyzer. (Radiometer 
America. Westkikc, Ohio). Results faim tlie ABL 735 wcrt ctimpaa*d to plasma a*sults 
sent to the acute caa lab V\'e enabled the leatua on the Radiometer ABL 735 which 
detects ;ind compensates tor tlie pasencc ot fetal hemoglobin. We (hen coiiipaa'd the 
whole bk^xl luial bilinibin asults obtained in our POCT kxation \\itli that ot the 
plasma samples sent iti the acute care laborator>' (Dia/o methodology ). Results: Our 
findings are outlined in Table I. 
Table 1 (n =" 24 samples) 



WD vs p 



WB V5 P 



\VB vs P 

2 4 


1 16 


6 2 

1 04 




2 3 



4 3 

4 1 

1 ()2 


4 3 





5 1 

5 7 




1 (>7 


5 2 



5 7 












2 5 



I 1 


1 1 





(1 78 


11 2 



7 7 



3 2 


7 1 

6 3 

1 11 




3 4 



Average of results: >VB measurement = 4.72 mg/dL, Plasma measurement = 4.98 mg/dL 

WB - Whole blood measurement in mg/dL 
P - Plasma measurement in mg/dL 
WB vs P - Whole blixxl to Plasma correlation 

Conclusions: The whole blood to plasma comslalions ranged from 0.22 - 1.16 (.22 
found at the extreme low measuremenLs) indicating the importance of consistent mea- 
suring techniques. It has been reported that variations of up lo 14. 8^:^ exist within labo- 
ratories however, the overall acceptable analytical difference is lO'^r. our results reveal 
an average difference of 5.5'7(. Although POCT should not replace laboratory meth^xl- 
ology. the rapid analysis may provide a reliable screening ttx^l. The ad\ antages ol using 
whole blood POCT methods are that I , results are obtained immedialeK ailm'. ing for 
appropriate interventions and 2. the sample si/c is "^(Kf snialler than the amount 
required for a plasma measurement. Further studies arc acquired to ev aluate the full 
implications of the significantly r«luced sample size on neonates. OF-02-1 36 



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m than other mask ventilation units? 

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mask ventilation. 

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Sunday, October 6. 3:0(M:55 pm (Rooms 20-21) 

MFaIKK I. I li/.ihclh Sctsknc MSN. Ri^tuial Shitiioi MD, Mkh;icl Pasqualc Ml). Joseph Cimller 
RRT Lehigh Volley HospiLil. Alleiilown. PA 

Introduction: The iniliation of mechanical ventilation is an integral clenKnt ol the in;magenient ol 
patienLs with significant trauma or neurological compromise, VentiIator>' support is rn.-quemly lifc- 
saving but nrprescnts a signifieiini nsk of moft>idit>- Patient discomlbn, airAay trauma ventilator- 
induced trauma, ;ind pneumtinia an: some frequent negative side cflecls from prolonged mechanical 
ventilation Met."hanical ventilation is also a major source of institutional and piitienl expense For 
these a'asi^ns it is prudent to liberate patients frtim mech;mical ventilation .is quickly as deemed clini- 
cally acceptable Currvnlly no iiK'lhod of ventilatory wciining has been clcirly demonstralcil .is supe- 
nor in the medical or suryical literalua' ' ' Rcccntl\ the a'spir.iior. ln.-i]iiciK> lo exhaled lidal vulunie 
(F/T\') ratio h.Ls gained jx^pulonty as an excellent Kinnnclei nl llic p.ilicin\ ability lu pcrlnmi spon- 
taneous brvatliing trials.'' Currently, information on value of these p-inimclen. in ihc ICU 
has been limited The goat of our study was to dctcnninc if the FAV nitio <I05 and maxmium inspi 
ratory pa-ssua* IMIP) more negative than -20 cm H;0 follovsed by a .l(>-minule spontaneous breath- 
ing tnal would be indicative of the tniumalized and/or neumlogically impaired patient's ability to be 
liberated from nKxhanical ventilation in a tinK'ly and s^ife fashion, Mi'thofLi: We performed a 
pntspeclive e\ aluation of the F/T\' and MIP for extufialion involving patients age 18 years or older 
admitted to a level one Trauma-Neuro ICU who receivetl mech.uiic;i] \eiililalion for more than 48 
houfN. Once the patient was deented clinically stable and a candidate lor possible extubation F/TV' 
and MIP nxrasurcmcntN were pertomied If llnr F/TV <U)>andlhc MIP was more negative than -i!! I 
cm H4J the patient was given a 3l>minute spontaneous breathing tnal on 5 cm H;() of CPAP via an 
mtemal ventilator fiow-bv system, Dunng the 3()-minuie breathing tnal the patient was monitored for 
hemodynamic and pulmonary stability based on acceptable TNICU cntena. If the patient maint;uned 
clinical stability . the p.itienl v^as liberated from the ventilator If not, the patient was re-turned lo pre-vi 
iHis ventilator pararrKters Results: M patients were ena>lled. of which .'^7 were admitted w ith the 
diagnosis of multiple trauma ;ind 22 w iih the diagnosis of cltised head injury . b2 of these patients 
were successfully libemled frv>m the \eniilaior with noadverst.- cffecis Tlie luo patients u ho failed 
the breathing tnalsvv ere re-intubated within 30 minutes due lo upper airway obstruction and nol sec- 
ondary to poor pulmonary mechanics. By utilizing this methtxJ of weaning we were able to reduce 
ventilator duration by 36 hours (7.5 reduced to 6-0 days) and decrease length of stay in the TNICU by 
4Shour^(9 2irducedto7 12days). Pre-study patient jxtpulation had an mean age of 42 years — study 
group mean age same. TRISS 71 compared to 0.81 ; ASCOT 0.7 1 compared to 0,83; and Glasglow 
score 9,2 compared to 8 8 These reductions lead to a decrease in patient discomfort and costs. Con- 
clusion: Our study re'sulLs demonstrate that utilizing the F/TV and MIP measurements are a reliable 
indicator of the palienis ability to maintain acceptable hemodynamic and pulmonary stabdiiy dunng 
spontane<.)u.s bre'athing tnals and post extubation m the TNICU patient population 

1 , Bochard L [?aass A, Benito S. et al. Comparison of three methixLs of gradual withdrawal from ven- 
tilatory support dunng weaning tram mecharucal ventilation, .\m J Respir Crit Care Med 1 994; 

2, Esteban A. Fnitos. Tobin MJ. et al. A companson of four methtxis of weaning from mechanical 
venlilalion. N Engl J Med 1995; 332:345-350, 

3, Esteban A. Alia I. Gordo F. et al Extubation outcome after spontaneous breathing trials with pres- 
sure support or T-tube Am J Cnt Care Med 1997; 156:459-465, 

4 Epstein SK. Etiology of extubation failure and the predictive value of rapid 

shallow bftathing index. Am J Respir Crit Care Med 1995;152:545-549. OF-02-001 


Alt Salim. MD: Kenneth Miller. RRT. MEd ; Williuin Dougheny. Ml^; Steven 
Pyne. RRT.BS; Lan^ Mann. RRT; Robert Leshko. RRT; Joseph (Jrollcr. RRT; 
Susan Adam RRT, 
Lehigh ViiJIey Hospital. Alleniown. PA 1 8 105 

Introduction: Approximately 20% of patients with significant inlraeerebral injur> 
develop acute lung injury (ALI). Conventional lung-protective \entilat017 strategies 
such as permissive hyper-capnia. prone positioning, and elevated mean airway pres- 
sure ulili/alion often contrihuie lo further intracerebral pressure elevation hy reduc- 
ing cerebral perfusion pressure. This can increase the likelihood of a negative out- 
come in this patient population, Hyputhe.sis: High Frequency Percussive 
Ventilation (HFPV) can improve oulconics in patients with intracerebral injury who 
develop ALI by stabilizing or reducing intracranial pressures (ICP) and by improv- 
ing oxygenation. Patients* and Methods: This is a retrospective case series over a I 
year period of patients with sigmllcanl head injury who developed ALL Significant 
head injury was defined as a Glasgow Coma Score (GCS) <X. All patients were 
managed via the guidelines dictated by the Brain Trauma Foundation. The presence 
of ALI was defined by the American-European Consensus on ALI, HFPV was 
instituted as a ventilatory .strategy in patients who failed conventional lung-protec- 
tive ventilatory management. Failure was defined as a PaO:/FI02 ratio (P/F) <200on 
positive end-expirator\' pressure (PEEP) >1 3cm/h:0and intracranial pressure (ICP) 
>2()mm/Hg, Only patients with ICP monitors were included in this study. Data 
regarding P/F ratio and ICP were compared before and after Ihe institution of HFPV 
t VDR-4. Percussionaire. Sandpoint, ID) as a ventilatorv strategy. Results: HFPV 
was utilized for ICP and ALI management for a total of 6 patients over the 1 year 
period of this study. Data is expressed as + SEM. 


4hrs Posl HFPV 

16 hrs Pom HFPV 

P/F ratio 

86.8 + 7.0 

198.0 + 21.7- 

.^2I).8 + .17.3'* 


31. ."5^5.4 

18.7 t3.1* 


*p<0.01 vs. HPFV. **p<0.01 4hrs. #p<0.05 vs. 16hrs 

Conclusion: Ventilatory management with HPFV produced a significant improve- 
ment in oxygenation with an associated reduction in ICP, Therefore HFPV may rep- 
resent an important new ventilatory modality in the management of ALI in head 
injured patients. OF-02-016 

Department of Cntieal Care. Maine Medical Center. Portland. Maine. 

High frequency oscillatory ventilation (HFOV) is a proven modality in the pediatric population. Tnals 
are now underway to prove efficacy of the oscillator for the adutt patient with adult respiratory distress 
syndrome (ARDS), We successfully oscillated two women weighing 138 and 144 kg respectively with a 
diagnosis of ARDS on SerLsorMedics 3 1 OOB oscillator Case 1 : 35 y ,0. white female, weighing 1 38 kg. 
BMI 54. presented to the ED with complaints of chest pain and dyspnea after a 10-day prodrome of 
upper respiratory tract symptoms. Initial evaluation revealed a complicated parapneumonic effusion. 
Because of exiensne kxulations. she u as taken lo the operating nx)m lor thoracoscopy and lysis ol 
adfiesion-s, Dunng the surgical procedure, she became extre'mely difficult to oxygenate and ventilate, 01 
> 80. and was placed on SensorMedics 3100A HFOV; APW. Paw 40, lOO^v RO.. 3 Hz. Ti 339f . Row 
35 Lpm, and power 10, CXR was compatible with ARDS. Initial ABG obtained on HFOV showed, pH 
7 14. PCO; 62. HCO3 2 1 . PO: 63 She was changed to SensorMedics 3 1 (X)B; A P 80. Pau 38. 1 00^^ 
FIO;. Hz 3. Ti 33'S. and power 5.5. The patient stabilized and the F10;> was quickly weaned to 53*^ • She 
rcmajned on HFOV ftff 4 day s. u as then weaned to eon\ enuonal \'entiIation. She was di.scharge to a 
rehabilitation hospital on day 162 uithout the need for oxygen. Case 2: 42 yo, white female, weighing 
144 kg. BMI 58-5. was admitted after a motor vehicle accidenL which resulted in long bone fractures, 
and significant chest and facial trauma. ARDS developed on day 1 8 secondary to staphy lococcal sepsis 
Multiple manipulations uith conventional ventilation and prone positioning failed to provide oxygena- 
tion. 01 62. The p;itieni was placed on 3I00A; A P73. Paw 45. RO: lOO^f . 5 Hz, Ti 33f?c. flow 37 Lpm. 
power 10, 01 52, Oxygenation improved, but ventilation was difficult despite manipulations of H/. cuff 
leak, and Ti. The paUent was then placed on the 3 l()l)B; A PM, Paw 33. HO: 53'7f . 5 Hz, Ti 5(K^. 28 
lpm flow, power 4,5, Oxygenabon and ventilaiion were achic\cd u ilhoul difficulty She remained on 
HFOV for 1 8 days and was eventually discharged home without respiratory symptoms. These two very 
large adult patients with BMI greater than 54 failed con\cntional ventilation, from both oxygenation as 
well as a ventilation perspective, despite multiple manipulations. There* were well oxygenated but were- 
nolabletobe ventilated with model 3100A SensorMedics HFOV Both patients were adequately venti- 
lated with tfie model 3ilM)B wiihlitranonof Ti.and HZ. witlioul tfk.- need for cuff leak. This was felt to 
be due to larger tidal volumes delivered for a given A P and an increase in available bias flow Major 
problems eiKouniercd and solved included: overheating of the dnvCT resulting ma lowered effective A P 
and maintenance of alvetilar volume dunng suctioning and hospital generator lesting. Hemodynamics, 
including oxygen delivery, actually improved with the use of HFOV. 

Improvement of Oxygenation Index 


RRT. Anne Francis RRT. Gail Whitford RRT. Gary L, Weinstein MD. 
FCCP, Presbyterian Hospital of Dallas 

INTRODUCTION: It has been conceptualized that "the immediate post-operative 
patient might be ideally suited for simple automatic feedback modes that provide a backup 
form of support" (Respir Care 2(>02;47( 1 1:69-90). This study compared and contrasted the 
viability of utilizing an autofeedback. closed-loop weaning approach to immediate post- 
op patients, with an emphasis on how that might impact therapist interactions with the 
ventilator. The population was limited to ! S post-nperati\ e open-heart patients dunng one 
month of 2002 We compared a weaning approach that utilized the Seimens Serxo 300a 
ventilator and its available Automode/PRVC (Pressure Regulated Volume Control) with a 
standard SIMV/PS weaning approach, METHODOLOGY: The control population was 
weaned with the SlMV/PS approach using the following weaning procedure. When the 
patient demonstrated capability of spontaneous respirations, the RR was decreased by 2 
breaths at a time as quickly as tolerated, ultimately placing the patient on CPAP/PS. It 
should be noted that PS of 8-12cwp was utilized to overcome resistance in Ihe airway. The 
PRVC/Automode group was weaned as descnbed. Upon noting spontaneous respirations, 
the "set Vi" was decreased to 5rnl/kg/lB\V and "set RR" al 75-125'v of spontaneous RR. 
Both groups had an initial ABG drawn to correlate ETC02 and Sa02 monitoring. During 
the weaning phase, the HR. RR. Sponi, Vt. ETC02 and Sa02 were monitored to 
determine continued tolerance. An ABG was drawn for both groups following 
approximately 30 minutes of totally spontaneous respiration, Extubation criteria for both 
groups included: RSBl < 105. FVC > lOml/kg/IBW. MIP > -20cwp. RESULTS: In the 
PRVC/Automode population there was a M9e reduction in therapist/ventilator 
interactions. As indicated in the following tables, a 247c reduction in tola! time on the 
ventilator was also appreciated for Ihe PRVC/Automode group. 

Patients in PRVC/Automode group 


Averace time on \entilaIor 

4,125 htiurs 

Shortest time on ventilator 

1,75 hours 

Longest tune un venlilator 

6 hours 

Average # of therapisi/venlilalor interactions 


Patients in SlMV/PS L-roup 


AveraL'c time im vcnllLiiur 

5.4 hours 

Shiirlcsi iiinc on \cnUlaIor 

3 hours 

Lon^^est time on venlilator 

9.5 hours 

Average # of therapist/ventilator interactions 


CONCLUSION : We found the PRVC/Automode approach to weaning to be an alterna- 
tive that IS both efficient and safe. This approach appears to provide Ihe therapist, that is 
dedicated to a busy ICU. with a tool thai permits rapid, safe, and ettccttve post-op wean- 
ing coupled with the flexibility to perfonn other useful tasks in the ICU. It should be 
noted that the re-inlubaiion rate for this study was zero. A larger, expanded studv is war- 
ranled to better quantify the usefulness of this approach. OF-02-044 

Respiratory Care • September 2002 Vol 47 No 9 


Sunday. October 6, 3:00^:55 pm (Rooms 20-21) 

DURING HK;II I- KEQUENCV oscillatory VENTILATION. John W. Berken- 
husch ' . Joseph I.) Tuhijs '-. DfpitrtiiiciUs ol fhild Health' and Anesthesiology', The Uni- 
\ersiiy ol Missouri-Culuinhia, Columbia, MO, USA 

Introduction: During mechanical venlilalion, continuous, non-invasive monitoring of CO2 
may he of benefit by limiting the need for repeated arterial blood gas (ABO) and 
facilitating proactive rather than reactive ventilator adjustments. Although end-tidal CO: 
monitoring is frequently used in the pediatric population, technical considerations prevent 
its use during high frequency oscillatory ventilation (HFOV), We have previously 
dtKumented the accuracy of transcutaneous CO; (TC-CO;) monitoring during pediainc 
conventional ventilation. The current study evaluates the accuracy of TCco; monitoring 
during pediatric HFOV. 

Methods: The study was approved by the University of Missouri Institutional Review 
Board TCco; was continuously measured using a TCM3 TC-COi/O; device (Radiometer. 
Copenhagen. Denmark ). Prior to placement, the TC-CO; monitor was calibrated accord- 
ing to the manufacturer's recommendations. As clinically indicated. ABG"s were obtained 
and the simultaneous values for the PaCO: and TC-CO; recorded. Statistical evaluation of 
the anerial-transcutaneous CO; difference was performed using Bland-Altman and linear 
regression analyses. To evaluate the accuracy of the TC-CO; device at higher PaCO; val- 
ues, we also compared the artenal-iianscutaneous CO; difference for PaCO; values < 50 
mmHg and with the diflciencc tor PaCO; values > 50 mmHg using an unpaired Student's 
l-test. A/) value of < 0.05 was considered significant. 

Results: 100 sample sets were obtained from 14 patients (8 boys. 6 girls) ranging in age 
from I day to 16 yr (3.5 ±4,6 yr), and in weight from 3.1 - 85 kg ( 18.5 ± 22.4 kg). Eleven 
patients were receiving vasoactive agents including dopamine (2-15 mcg/kg/min). dobu- 
tamine (5-10 mcg/kg/min). epinephrine (0.05-0.2 mcg/kg/min) or nicardipine ( 1 
mcg/kg/min) The absolute arterial-iranscutaneous CO; dilTerence was 2,8 ± 1.9 mmHg. 
The arterial-transcutaneous CO; difference was 0-2 mmHg in 51/100 values. 3-5 in 
41/100 values and >5 in only 8/100 values. Linear regression analysis of arterial vs TC- 
CO; revealed a slope of 1 .04. an r value of 0.96 and an r- value of 0.94 (p<0.000i ). 
Bland-Altman analysis of the entire group revealed a bias of 2.1 mmHg with a precision 
ol 2 7 mmHg When PaCO; was < 50 mmHg. Bland-Altman analysis re\ealed a bias of 
1 9 mmHg and a precision of 2.8 mmHg compared to a bias of 2.3 mmHg and a precision 
of 2.6 mmHg when PaCO: was > 50 mmHg (p=NS). 

Conclusions: TC-CO; monitoring provides a continuous, clinically acceptable, estimate 
of artenal CO; over a wide range of PaCO; values during HFOV in infants and children 
Given that patients receiving HFOV tend to be more critically ill. accurate, continuous 
monitoring of ventilation in these patients is particularly desirable and may facilitate more 
proactive ventilator adjustments. Additionally, this may be especially useful during the 
initiation of HFOV when large changes in PaCO-- may occur. 


MPH. RRT. Dana Simonson BA. Alain Broccard Mn n.ivid \'>nfi MD Inhn M:inni 
MD, John Hiiiehkiss MD. Regions Hosp./Univ of MN, St. Paul, MN. Background: 
During pressure-cycled ventilation (PCV). tidal volume ( VTl and end expiratory lung 
volume ( EEL V) are detemimed by pressure settings and respiratory system mechanics. 
However, recent lung \ olume history may also affect VT and EELV, therefoa-, we 
ventilated rat lungs over a range of settings after either lung collapse or lung 
recmitment. Methods: Lungs from .Sprague rats (n=4) were extracted and suspended 
within an air-tight jar; the trachea.s were in communication with a pressure cycled ven- 
tilator. VT and EELV were monitored by tracking the jar pressure as calibrated to vol- 
ume by a calibration syringe. VT and EELV w ere obtained for a range of PCV settings 
( lO/."!. I.V5, 20/5. 25/5, X/5. 35/5) after either lung collapse between sellings 1- 10 
cmH20 for 5 minutes between settings) or after lung recruitment (PCV of 35/5). 
Results: When lung collapse was induced between PCV settings, mean VT increased 
with increasing Pset (left llgure-ascending or lower limb) and mean VT was 
significantly greater after lung volume recruitment (left figure - descending limb). 
EELV also increased with increasing peak PCV settings (right figure - ascending or 
lower limb)) when lung collapse was induced between settings but EELV wa.s 
maintained as peak PCV settings were decrea.sed after lung recruitment. Thus, the 
lungs remained open alter lung recmitment in spite of decreasing Pset. Conclasions: 
VT and EELV were markedly affected by recent lung volume history. Thca-fore. lung 
mechanics are dynamic and VT/EELV may be altered by activities such as suctioning 
or recruitment maneuver. AHA SDG 9930184N;NIH SCOR 50152. 


i 6 j^ / 

o - ^r . 

S IS J5 J5 

Ptvmur« (cniHZO) 

%• ' ^'"'''^ 

j; 5 IS JS 35 
p%mmK* (cmM?0) 


OXYGENATION RELATIONSHIP. Alexander Adams MPH. RRT . Dana Simonson 
BS. Sungchul Lim MD. John Hoichkiss MD. Da\ id Dries MD, John Manni MD. 
Regions Hospital/Llniv of MN, St. Paul. MN, Background: A direct, but not necessarily 
linear, relationship is assumed to exist between mean lung volume and oxygenation. This 
study investigated the relationship between lung volume and oxygenation in three porcine 
mcxlels of acute lung injury. Methods: In deeply anesthetized pigs, acute lung injury was 
induced by either 1 ) Oleic acid-induced injury (OAI) - OA was infused via pulmonary 
artery over 90 min (0. l-0.2ml/kg) 2) Ventilator-induced lung injury ( VILI) - pressure 
control ventilation was set to an inspiratory Ptp of 35 cmH20 o\'er 6 hours on FI02 = 
0.6(). 3) Pneumonia - Instillation oi StreptocoicHs pneumoniae inoculum \ia 
bronchoscope to lower lobes of both lungs and pneumonia was allowed to develop over 6 
hours. Injury was established when Pa02/FI02 = 80-140 inmHg, After stabilization of 
each injury model, a pressure generated (PEEP increased in 3 cmH20 steps from PEEP 
of 3 to 27 cniH20) volume -oxygenation cun'e was constructed. Lung volume was 
recorded by respiratory inductive plethysmography as oxygenation was monitored con- 
tinuously by an indwelling ABC analysis catheter system. During the protocol, 
ventilation was set to minimize lung excursion (f=30. VT =150 niL). Results: For the 
OAI and PNM mcxlels. Pa02 increased with increasing lung volume in a concave 
relationship. In PNM. Pa02 decreased after a certain threshold. The relationship was con- 
cave for the VILI model. Conclusions: The thre'c nuxlels displayed differences in their 
oxygenation response to mcreasing lung volume - as increased by incrementing PEEP. 
The results suggest thai different pathophysiological factors determine the oxygenation- 
lung volume relationship ;ind that ventilatory strategy must be customized to treat the 
prevalent iung injury. AHA SDG 99301H4N;NIH SCOR 50152. 


Julie Harrison. RRT : Dawn Selhorst. RRT; Scott Penfil. MD; Edward Cullen. DO; John 
Rendle, RRT; James Hertzog. MD. Departments of Respiratory Care Ser\ ices and Anes- 
thesiology and Critical Care Medicine. Alfred I. duPont Hospital for Children. Wilming- 
ton. DE. 

Introduction: Teaching and evaluating clinical knowledge, skill, and problem solving 
should include didactic and interactive activities. We developed a Mechanical Ventilation 
Learning Laboratory, hypothesizing that Respiratory Care Practitioner (RCP) knowledge 
and ability in the principles and application of mechanical ventilatory support to children 
would be enhanced. 

Methods: A dedicated space, separated from clinical activities, was established for this 
project. In this laboratory, equipment is available to simulate the process of mechanical 
ventilation, including a mechanical ventilator and a Michigan lest lung. A RCP 
participated in an individualized session using the Siemans Ser\o 300 ventilator with a 
Respirator) Care Clinical Instructor and a Pediatric Intensivist- A written examination 
about the function of this ventilator and a series of Likert scored questions on RCP 
impressions regarding their experience, ability, and comfort level with the ventilator was 
completed- A modified objective structured clinical exam (OSCE) was then performed. 
testing fiinciional abilities with the ventilator, problem solving abilities, and knowledge of 
advanced respiratory care concepts ("pre"). An educational intervention was then 
performed, including review of the written exam and OSCE. A study period of up to 30 
minutes was provided where the RCP could use the resources of the laboratory as ihey 
wished. Finally, all testing was repeated at the end of the study period ("post") and 
approximately 3 nionlhs after initial testing. Statistical testing with General Linear Model, 
paired sample t test, .md W'llcoxon Signed Ranks test were performed to evaluate changes 
in test scores and responses o\er time, 

Result.s: 30 RCP's participated in the study. There is statistically significant improvement 
(p< 0.(X)l I in performance of the written exam and the OSCE after education that 
persisted through 3 months, although there is a drop-off in pierformancc. 


Mean Score ± SD 




23.1 ±5.8 

^ months 

17.3 ±7.4 


Mean Score ± SD 


47.4 ±6.8 



^ months 

50.3 ± 8.4 

Likert scored questions regarding RCP 
impressions demonstrated a statistically significant improvement after the educational 
intervention in the RCP level of comfort and confidence with setting up and using the 
Servo 300 as well as with understanding advanced ventilatory strategies (i.e. PRVC. 
inverse I: E ratio, lung protective strategies), 

Conclusipn^: The Mechanical Ventilation learning Laboratory proved to enhance the 
knowledge and ability of the RCP in the principles and application of mechanical ventila- 
tory support to children A dnip-otf in performance occurred with time, suggesting that 
ongoing training sessions might be necessarv to maintain the RCP knowledge base. 
Supported by The Nemours Foundation Education 
Innovation Program Grant OF-02-072 


Respiratory Care • September 2002 Vol 47 No 9 

Sunday, October 6, 3:00-4:55 pm (Rooms 20-2 1 ) 

A Comparison of (.as Sources and I:F, Ratios and Their Effects on Aerosol 
Dfpnsilioii During Conventional \'entilation 

BnanStniih. KRI. Jason Higgins. BS RR F. Anthony Dal Nogaa*. MD 

Parkland Health and Hospital System, Dallas. Texas Depanmenl of Respiratory Care 

Background: Several factors arc identified in the cunvnt literature as contributors 
to aerosol deposition m the small airways. The effect of the gas source, whether it 
IS continuously by a tlowmctcr or intemiittcntly from a ventilator, as well as the set 
l:E ratio on the ventilator are of particular interest in our study. We sought to deter- 
mine if either gas source is more efficient and whether greater l:E ratios with each 
method has an effect on optimal deposition. 

Method: An in-vitrx) lung model with in-line bacteria fillers was designed for the 
purpose of this study. We compared aerosol deposition when generated by a Hetir IIHX) 
\enlilatordunng inspiration only versus continuously by a wall soureeat l:H niiiosof 1:.^ 
iind 1 :6, Ten iilbutenil nebulizers each containing }• mis of albuterol w:ls delivered in-line 
using the traditional port on the inspiratory side of a ventilator circuit for each aerost)l 
generator at each 1:E ratio. The nebulized aerosols generated from the wall were deliv- 
ered at 8 liters/minute for 7 minutes. Nebulized aerosols generated fR»m the ventilator 
were driven dunng mspiration only for a time penod of 31) minutes. After e;ich nebulizer 
was completed, filter samples were collected 6 cm to the right ;uid left of a ^)«' bifurca- 
uon representing dist;d airways. The filters were then saturated with 7 mis of ethanol in a 
sterile container for a period up to 1 2 hours. Samples fmm each container were analyzed 
with a spectrophotometer set at 278 nanometers in onJer to calculate albuten>l absorption 

Results: Absorption amounts were converted to mg/ml: 

l:L ratio 1:3 

I:E ratio 1:.1 

ItK ratio 1:6 

1:K ratio 1:6 






Mean- 1015 

Mean-. 1:45 

Mean- .0640 

Me;in- .0579 





Range- .078-. 121 

Range- .095-160 

Range- .(>4t)-.080 

Range- .045-.095 


Mean- .08 14 

Mean- .0813 








Range- .054-. 109 

Range- .054-. 107 

Range- .053-.088 


Conclusion: With this study, we attempted 10 isolate two factors that have an 
effect on aerosol deposition. We demonstrated that intemiiltent ncbuli/.alion (inspi- 
ration) along with longer inspiratory tmies provided notably imprn\ed aerosol 
deposition. Results also indicated that when shorter inspiratory limes were used, 
there did not appear to be a noticeable difference between nebulization from the 
wall outlet versus nebulization from the ventilator. We feel that this data can be 
useful clinically with those patients who are intubated and requiring bronchodilator 
therapy. OF-02-081 

Schwann. RRT. CPFl' : Robert M Kacmaa-k, PhD. RRT, FAARC, Dean R. Hess, 
PhD, RRT, FAARC. M;Lssacliusott.s General Hospital and H;irvard Medical 
Sch>xil, Boston. MA. 

Backj-round: Oxygen administration is usually requiiied for patienLs with acute 
respiratory lailua" requiring noninvasive ventilation. For the BiPAP ventilator, this 
is accomplished by O: titration into the mask or ventilator circuit. We have iinccdo 
tally noted that arterial oxygen saturation v;iries with the leak port itnd BiPAP sel- 
lings. HypoUiesis: Oxygen delivery during BiPAP is affected by the leak port and 
BiPAP settings. Metliods: A Puritan-Bennett 72(X) ventilator (Tyco, Carlsbad, 
CA) was attached to one chamber of a dual-chambered test lung (Michigan lnstr\i- 
menls. Grand Rapids, Ml). A lift h:u- was placed between the chainbers such that 
the ventilator triggered simulated spontanetnis breatiting of tlie second chamber. 
The second chamber was connected to the head of a manikin. A Mirage orona.sal 
face mask (Resmed. Poway, CA) was attached to the manikin. A single limb circuit 
was attached between tlie mask ;ind a .Synchrony BiPAP ventilator (Respironics, 
Pittsburgh. PA). Tha'e leak pons were compared: leak in the Mirage mask, 
Respironics Plateau Exhalation Valve (PEV) with Mirage mask leak port occluded, 
and Respironics Disposable circuit with Exhalation Port ( EP) and Mirage mask 
leak port cxxluded. BiPAP settings of 10/5, 15/5, 20/5, 15/10/ 20/10, and 25/ 1 cm 
H2O were used at respiratory rates of 1 5 mid 25/min. Oi was titrated into the mask 
or into the circuit at the ventilator outlet using flows of 5 and 10 Umin. CO2 was 
titrated into the lung mcxlel to prixiuce an end-tidal PCO2 of 40 or 75 nun Hg. Oi 
concenu-ation was measured between the manikin head and the test lung (PB 7820 
oxygen monitor). Results: The Oi concentration was greater when O2 was titrated 
into the circuit with the leak port in the inask, whereas O2 concentration was greater 
when O2 was titrated into the mask for the PEV and EP (see Table). Ot concenU^ 
tion was lower with the leak port in the 
mask (P<O.OOI ), a higher IPAP 
(P<0.00 1 ), and a higher EPAP (P<O.0OI ). 
Delivered O2 concentration was not 
affected by respiratory rate (P=0.22) or 
exhaled PCO2 (P=0.74). Conclusions: 
Delivered O2 concentration during BiPAP 
is a complex interaction between the site 
of the leak port, the site of O2 titration, the 
settings on the BiPAP ventilator, and the O2 flow. Because of this, it is important to 
continuously estimate arterial oxygen saturation using pulse oximetry when 
patienLs with acute respiratory failure are receiving noninva.sive ventilation using a 
BiPAP ventilator. OF-02-082 

EilTccl of Ix-ak Port and 0: Titmlion Sile on 
Dclivcn:d O; Concentnuion 




Oi inio inasli 

.S Umin 








.)., into cirvuil 

3 LVmin 









Mark J. Heulitt MD . Patricia C. Wankum MD, Shirley J. Holt RRT, 

Tracy L. Thunman, Renee A. Hall, M.S. and Pippa Simpson, Ph.D. Pedi- 
atncs, UAMS/Arkansas Children's Hospital, Little Rock, AR. 
Background: The goals of modem mechanical ventilation in infants and 
children have focused on preventing overdistention by limiting tidal vol- 
ume, thus volutrauma. Exact knowledge of both inspired and expired gas 
volumes with a sufficient level of precision is essential to optimize venti- 
lator settings utilizing this lung protective technique. However, the opti- 
mal site for monitoring volumes in these patients is unclear. Objective: 
The objective of our study was to determine if volumes could be 
accurately measured utilizing pressure support ventilation (PSV) and 
positive end expiratory pressure (PEEP) in piglets utilizing software 
compensation for circuit compliance measured at the ventilator. 
Methods: Volume measurements were performed, on six neonatal and 
six pediatric piglets, ventilated with the Servoi'™ using PSV and PEEP, 
with and without circuit compliance compensation. We compared 
volume measured at the airway utilizing a pneumotachograph to volume 
measured at the ventilator. Results: The use of circuit compliance com- 
pensation improves the agreement between the two volume methods for 
neonates (median, range: 0.84, 0.64-0,91 vs. 0.92. 0.70-0.96). Among 
pediatric animals, there is improvement in agreement between the two 
volume methods attributable to circuit compliance compensation (0.69, 
0.39-0.97 vs. 0.92, 0.68-0,96). In addition, the variability in agreement 
lessens with circuit compliance compensation. Conclu.sions: Our results 
show that volume can be accurately measured away from the airway in 
neonatal and pediatric patients if circuit compliance is compensated. Dis- 
closure: Unrestricted grant from Siemens Medical Systems 


BREATHING. Mark J. Heulitt MD, Patricia C. Wankum MD , Shiriey J. 
Holt RRT, Tracy L. Thurman. Pediatrics, UAMS/Arkansas Children's 
Hospital. Little Rock. AR. 
Background: In adult patients, changing the inspiratory flow rate has 
been shown to improve patient-ventilator synchrony. However, little is 
known about the effects of increasing inspiratory (low on work of 
breathing (WOB) in neonatal and pediatric patients. Objective: The 
objective was to evaluate the effects of inspiratory rise time (IRT) on 
WOB and the response time of the ventilator. Methods: Twelve neonatal 
and 12 pediatric intubated, sedated, spontaneously breathing piglets were 
ventilated in pressure support ventilation (2 cm H20), PEEP (3 cm H20) 
with IRT 1% and 10%. utilizing flow triggering on the Servo 300™. 
Data were collected using both a computerized respiratory monitor and 
data acquisition system to evaluate differences in the duration of inspira- 
tory effort, trigger response time, and any significant pressure or flow 
variances relating to IRT. Response time of the ventilator included quan- 
tification of the slope of the inspiratory flow curve and the area of How 
from the baseline pressure to when expiration began. In addition. WOB 
was measured. Results: When comparing IRT \% to IRT 10% we found 
no differences in WOB in neonatal animals, however, there were differ- 
ences for ventilator work in pediatric animals (p=0.002). When 
waveforms were compared, we found no differences in the animals' 
effort to trigger, however, we found differences in ventilator response 
time. In neonatal animals, the slope of inspiratory flow was faster for 
IRT 1%' (174%, p=0.002). The same was true for pediatric animals 
( 1 13%, p=0.(K)2). Conclusions: Adjusting the IRT, had no effect on 
WOB in healthy neonatal and pediatric animals, but did affect the avail- 
ability of flow during triggering of the ventilator. Disclosure: 
Unrestricted grant from Siemens Medical Systems 




Sunday, October 6, 3:00-4:55 pm (Rooms 20-21) 

Visit our online store at 

where you can order all your 
respiratory educational and 

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including books, audiO 

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individual independent 
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RRT . Tom Malinowski. RCP RRT. FAARC, James l.amben] MD Inova Fairfax Hospital. 
Falls Church. V A, 

BACKGROUND: Correcting for ventilator circuit compressible volume (CV) is imponant dur- 
ing low tidal volume ventilation. Two methods used to correct C V include substitution of a 
pediatric ciicuit for a standard adult volume ventilator citxrujt. or the correction lor CV via 
fomiula. We sought todetemiine if either method was supenor as determined by FECO;^^ 
and/or auto-PEEP using a bench model METHOD: One chamber of a dual chambered test lung 
( VentAid'" Training Test LungJ wa.s connected to a mechanical ventilator set to specific parame- 
ter^ (table I ). 320 ml/minute of 100% CO: was continuously bled into the test lung to simulate 
CO2 pnxiuction A caition dioxide sampling line was placed between the lung chamber and the 
ventilator cireuit wye. Three dcadspace volumes ( 1 (X). I .SO. 2(X) mlj were added between the 
wye and test lung to mimic physiologic dcadspace CV was determined by a previously 
described standard pnxess; occlude the ventilator wye. observe corresponding volume and peak 
pre,s.sure during ventilator cycling, dividing the tibserved volume by the peak inspiratory 
pnsssure minus PEEP. The CV was then added to the set tidal volume. The FECO2 was allowed 
to siabill/e between settings and pnor to recording values (>l minute). 


Imposed VD 























20 1 4.50 
Test lung compliance f 

(12 Ucm H;0 





FECO, % 

Feds Circuit 
FECO, % 

Comp. Vol. Corr. 
FECOt % 








































1 1 






















In this bench model, CO; clearance beyond baseline levels was enhanced most by correction for 
CV. rather than by substitution with a pediatric circuit. Auto-PEEP was not observed in any of 
the groups. DISCUSSION: Correction for CV was not idenbfied in the initial ARDSnei trial 
publication, but has subsequenUy been identified as a factor worthy of consideration. Correcting 
tor CV enhances C02 clearance and may reduce dyspnea associated with 
low tidal volume strategies, OF-02-153 

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Donna K. Tearl CRT . Timothy J. Cox. KR'I". James H, HL*r1zog. MD. Depunmenls of 
Respiratory Care Services and Anesthesiology and Critical Care Medicine, Alfred I. 
duPont Hospital for Children, Wilmington. DE. 

Background: Preparation of technology dependent children for hospital discharge 
presents many challenges. Adequate training and education of caregivers, discharge 
planning, and coordination with the Durahle Medical Equipment (DME) and home- 
nursing companies must be completed. A priKess utilizing multiple Respiratory Care 
Practitioners (RCP) to achieve this may not be efficient. We evaluated our model 
where a dedicated RCP discharge cotirdinator provides education and coordinates dis- 
charge planning. Method: In June 2000. we instituted a system uiilizmg a dedicated 
RCP discharge coordinator to manage the needs of technology dependent patients. 
This system provides a single contact for caregivers and outside agencies, a single res- 
piratory care educator for the caregiveni. and utilizes a clinical pathway involving the 
entire multidisciplinary team. Patient length of stay (LOS), number of training ses- 
sions, and customer satisfaction were evaluated before and after implementation. Sta- 
tistical analysis was performed using l-lest. Mann Whitney U test, and Chi Square. 
Results: Data was gathered on 76 technology dependent patients from 1999-2001. 
Table 1 shows LOS. LOS decreased 41% after implementation. This decrease did not 
reach statistical significance (p = 0.055). Table 2 shows the results of two surveys ask- 
ing ( 1 ) DME personnel if they were satisfied w iih the quality of caregiver training and 
(2) multidisciplinary team members if they were satisfied with the respiratory care 
educator's performance. Statistically significant improvements in satisfaction were 
demonstrated for both groups (p < 0.001 for DME, p < 0.002 for team). Average train- 
ing sessions increased 19% from 2000 to 2001 . 
Table I Table 2 





82 days 



48 days 









Conclusion: Our model of a designated RCP discharge coordinator/educator for tech- 
nology dependent patients was associated with increa.sed training sessions, increased 
satisfaction with the quality of caregiver training by DME personnel, and increased 
satisfaction with the discharge process by the members of the hospital multidisci- 
plinary team. Although not statistically significant, there was a trend toward a 
decreased LOS with this system. 


Dougla.s K. Orens. MBA. RRT. Lucy Kester. MBA,RRT,FAARC, James K. 
Stoller, MS, MD. FAARC, 
The Cleveland Clinic Foundation, Cleveland, Ohio. 
Back}>n>und: In the context of hospital growth and markedly increasing severity of 
inpatients' illness over time, changes in the volume and types of inpatient respiratory 
care services are exf>ected. To assess these changes in a large tertiary care hospital, we 
examined the trends in the volume, percent distnbution. and cost per patient <)f respira- 
tor) t-.ire services provided by the Sectmn of Respiraton Therapy at the Cleveland 
Clinic Hospital. Methods: I'he vtilume of respiratory cure services was tracked using 
CliniVision. (Mallinkrodt. St. Louis. MO). Actual fixed and variable costs were 
tracked using Transition Systems accounting software (TSl, Boston. MA.), which has 
been in use in our hospital since 1 99(__). The designation of "high volume therapy" 
was applied to those 5 services accounting for the highest proportion delivered in 1991 
Results: Table I presents the volume and types of respiratory care serv ices delivered at 
the Cleveland Clinic Hospital in the years 1991. 1996. and 2001. Despite a 47,8% rise 
in the number of hospiiali/ed patients per year from 1991 to 2001. the total number of 
high-volume treatments administered decreased slightly (by 1.9%). so that the number 
of therapies per patient declined by 34% (from 1 1.9 to 7.9). 
Table I . Type and Trends of High-Volume Respiratory Care Services Delivered 

Number of TrcalmcnLs hv Year 

% Change 
in Fraetion 
2001 vs. 1991 







47,498 (32'il 




22,513 (ll*) 

26,171 lISM 

16,(I0S 1 IK',; 1 

64'* T 



40..116i:s'; 1 

51,6:4(26',; 1 


ncenlive Spirometrv 




27* 1 


19,990 (19'iH 

13,898 (99tl 

11, .542 167,) 


Total Therapies 

202,728 (100<i) 

147,101 (100%) 

198,908 (1009H Patienis 
Reten ing Resp Care 








A concomitant 35^ reduction in cost (from $93.98 to $61 ,07 per patient) was 
observed. Over the decade analyzed, bronchodilalor therapies comprised a larger per- 
centage of all high-volume treatments (45'7f to 5?^f ). with a nsing proportion of thera- 
pies administered as MDls (25*^^ in 1991 to 33% in 200! ). Broncnopulmonar> 
hygiene demonstrated the largest reduction in absolute volume of respirator) therapies 
administered (71'';^ decline). Conclusions: We conclude that: 1. Dispute a nsing hospi- 
tal census, the absolute volume and the number of high-volume therapies per patient 
have declined between 1991 and 2001. 2. Amon" the 5 high volume therapies 
assessed, bronchopulmonary hygiene showed the largest absolute and prop*.)rtionaie 
decline in use, 3. In the context that the Respiratory Therapy Consult Senice was 
first implemented in 1 992, we speculate that these trends reflect the benefit of better 
allocation of respiratory care services conferred by use of a respiratory 
care protocol service. OF-02-086 

Clinical Outcomes with its Implementation 

Laura D. Smith, DO, Paul R. Bast, RRT . Thomas M. Kane, RRT, Jackie 

O'Biien, RN, Steven Trotlier, MD, Lisa Mansaro, RN, Carla Cappadoro. 


St. John's Mercy Medical Center. St. Louis. Missouri 

BACKGROUND: PVolocol-guided weaning of mechanical ventilation has 
been shown efficacious in the adult Intensive Care Unit (ICU) without 
harm to the patient. A Respii^tory Care-Directed Weaning Protocol 
(RCDWP) for mechanical ventilation (MV) was developed as a means to 
monitor and improve the quality of care of patients in the ICU. The 
purpose of this study was to evaluate the safety of a RCDWP. METHOD: 
An eight-month prospective, intei^entional study including aduU 
medical/surgical ICU patients receiving MV was conducted from May 1, 
2001 through December 31, 2001. Data collected was divided into two 
peiiods: four months prior to and after the implementation of the RCDWP. 
The Society of Critical Care Medicine Project Impact database facilitated 
data collection including days of MV. ICU length of stay, ventilator-asso- 
ciated pneumonia, APACHE II probablility of survival, and patient demo- 
graphics. Each patient underwent a daily screen peifomied by the Respira- 
tory Care Practitioner (RCP). A successful screen prompted initiation of 
our protocol by the RCP. Physicians were notified when patients passed 
their spontaneous breathing trial and ready for extubation. RESULTS: 
709 ICU patients were admitted to a medical surgical ICU over an eight- 
month period and 249 received MV. The average number of days on MV 
was 5.8, as compared with 6.2 prior to prottK'ol institution. Ventilator-asso- 
ciated pneumonia decreased from 20% (n=25) to 1 1.3% (n=14) after pro- 
Iwol implementation (p<0.05). Reintubation rate and numt)erof 
U-acheoslomies were unchanged. CONCLUSIONS: The implementation 
of a RCDWP with daily screening noted an associated decrease in the inci- 
dence of ventilator-associated pneumonia. This protocol safely accelerated 
the weaning prtKess with a trend toward decreasing the average number of 
days on MV, yet this was not statistically significant 


FAARC Pnmary Children's Medical Center Salt L^e City. Utah U.S.A. 
Background: Many respiratory care departments employ equipment personnel to 
process equipment for the respiratory care staff. Managers everywhere are being asked to 
reduced department expenditures in supplies and personnel. After supplies the equipment 
technician position is often the first to be eliminated- This abstract will explore die bene- 
fit of not only maintaining the equipment technician position but also expanding their role 
and value. This may include, budgetary knowledge, the ability to pertomi cost 
comparisons, and aJlow purchasing power. Direct communication with the RCP's will 
also streamline equipment needs. Method: At our facility we implemented such a posi- 
tion. This abstract focu-ses on the impact this position had on reducing disposable respira- 
tory supplies costs over the past three years (see figure one). In addition to cost saving 
efficiency. improvemenLs are unlimited in the areas of minor equipment, specialty gas. 
maintenance and repair. It is not just the cost savings issue, it is a contact person for all 
staff and management throughout the facility to oversee repairs, evaluate and acquire new 
state of the an equipment. A person in this position must have sufficient job training and 
knowledge of supplies so that they can identifv- pn:>blems and needs. One such example is 
the method of delivering blow-by 02. Traditionally this has been through a bag and mask 
which is not cost effective. Using a funnel and suction tubing connected to the flow meter 
provides a very inexpensive blow -by set-up. Over the next few years, several cost reduc- 
tions were investigated and implemented further dn\ ing down die overall cost (see figure* 
two). To improve staff awareness of disposable supply costs we implemented "Pnce is 
Righf " at department meetings. The concept is from "KX)I Ways to Energize 
Employees". Many RCP's are surprised of actual costs. Conclusion: There are pros and 
cons to expanding the role <^{ the existing equipment lechnici:in and or creating this posi- 
tion (sec figure three) VVc ha\e found that this position reduced respiraton c\[X'nses at 
our lacility Without supptirt from miinagement and administrators to gi\e the equipment 
technician freedom to explore, expand, and become involved, a program like this could 
not be successful. 

hgureCtnc Coa S«iiig» F*cb Yew FijwtTwd Co« S»vwp ofhnfitaottitMwi of Blow-by 02 



51M T 

t.dwcilion Expaua 

PontMc Ob Cd Piy 

Figure nvte Pn>'iK>dCcia' 


r c Uu cb U nt y^ < L ?tu pp> v c um — ' 
Burdeo Off Mana^ttneni 
Ob CaD AwUbilin 
Nctwot Wall Veodon 
(~>v«nce Eqiupfnail bvaluaioai 
StfcaoilDW Oideniif of F'^uipmcnl 
Networi *nli (Hho Itqunmcnli 
UtMaiD CapiUl tquipnvnt (^loUs 

. o/ ErpmietJ Rok of Fqiupdiaii TechfuctM OF-02-096 


Rh.spiratory Care • September 2002 Vol 47 No 9 

Monday, October 7, 9:30-1 1 :25 am (Rooms 18-19) 

STAY (LOS); Frank Miller. RRT . Cheri Schuler, RRT, RPr-T, Arccnio (ialindo, 
RRT. Miivo Clinic Hospital. Ptwenix, \L. 

Background: .'\ respiratorv therap) protcxol program wis implemenleJ on our 
medical-surgical tltwr. as an eleven (II) week pilot study. All patients » ith 
physician oi^iers for respiratory therapy, or a respiratory consult order, were 
placed in the protocol pRigram. The protocol program utilizes a severity/acuity 
scoring system to direct patient care in accordance » ith the AARC Clinical Prac- 
tice Guidelines. 

Methods: One outcome measure we chose to monitor was the impact on 
pulmonar>' diagnosis-related (DRG) groups LOS. The pulinonary DRCi groups 
we chose to monitor include; respiratory infection i DR(j 079 & 080 1, chronic 
obstructi\e pulmonary disease (DRG 088). simple pneumonia (DRG 08')). and 
respiratory sii;nil"icance(DRG099& l(X)). We had our Decision .Support 
Services (I^S^^ l pro\ ide monthly reports for tlie specified pulinon.iry related DRG 
groups and tiie associated a\ erage LOS for both the pilot study penod and the 
eight (8) months immediately prior to the start of the pilot 

Results: Eiach of the pulmonary related DRG groups showed a significant reduc- 
tion in hospitalized LOS. 

Impact to DRG Group 
Average LOS 



DRG Groups (079 & 080) 

DRGGrpup (088) 

DRGGaiup (089) 

DRGGaiups (099 & 100) 









DRG Cfoup LOS 

■ DRO Orwo (008) 

Conclusion: Implementation and utilization of therapist driven protocols appear 
to be effective in reducing hospital length of stays for patients admitted with a 
pulmonary i^lated diagnosis. OF-02-103 

RCP . Charles Rilcy. MD. Dtmald Romig. MD. Barii;ira Ben/aqucn. MSN. RN. Si. Vin- 
cent Hospital. Sanla Fc. New Mexico. 

A six-tnonth investigative study was perfomied in 1 75 patients in the critical caa* unit of 
a comniunit) hospital. The study hyptiihesis was that the less often the ventilator circuit 
was interrupted, the lower the incidence of acquiring V AP. In addition, modification to 
existing oral care practice would have a significant role in decreasing VAP rate as well. 
Existing patient care pn.>t(x;ol w;is mixlified to decrease exchange fa-quency for in-suc- 
tion catheters fmrn Q24 hours to Q7 days/pm while mechanical ventilator circuit 
exchange frequency was decreased from Q7 days to 030 days/pm. All change in practice 
standards were implemented simultaiieou.sly after educational sessions that outlined 
changes, studs puiynisc and pemxi Study data analysis included; number of 
mechoiiicalK \ciiiiUitcd paliciiis, xciili later acquired pneumonia (VAP) rates and ventila- 
tor da\s. Additional data aiuil>/cd included .i\cragc length of mechanical ventilation and 
supply expense per ventilator day. Study in-line suction ;ind mechanical ventilator circuit 
exchanges would immediately lenninale and reveil to pre-study clinical practice if the 
VAP benchmark was ever exceeded. 

Median data for benchmarking purposes was derived from aggregate data collected over 
a 2 year period. In the Table below. Quarter One represents median, pre-study 
benchmarked data. Quarter Two and Three represent impact of clinical practice changes. 
Evidence demonsmiied that with modification to existing practice surrounding oral care 
and equipment exchange frequency, even with an increase in \ eniilator da\ s. a marked 
impact on decreasing VAP rates was reported. Average for the stud) penod revealed 
1 1 .56 VAP rale opposed to the 14.14 benchmarked VAP rate. This represents an average 
decrease in critical care unil VAP rate by -2.58 or -1 8.267f . Average length of mechani- 
cal \ enulaiion increased during the siud\ penod but dat;i deemed inconclusive and not 
stud\ related. Operational expenses for the penixl \\ere also decreased. Average expense 
per \enulalor day signiticanUy decreased S 1 7.8 1 to 57.74 representing a 56.2'7c reduction 
in operational suppK expense 



Vt'iu Days 




Variance # 

Variance *7r 

































We recognize that continued research on this topic is required. Subsequentiy. this study 
supports the ability to modify clinical oral care while decreasing the exchange frequency 
of routine in-line suction catheter and mechanical ventilator circuit changes while reduc- 
ing costs associated with providing mechanical ventilation without negatively impacting 
patient care outcomes, OF-02-1 05 

Dekeon. RRT. Ronald Dechen RRT. M.S.- Critical Care Support Services. 
University of Michigan Medical Center, Ann Arbor, Ml 

Background: Community based RT training programs face a growing dilemma of 
providing adequate clinical enrichment programs for RT students. Students may 
therefore lack the needed experience to provide specially supportive care upon 
completion of their matriculation. In addition, this clinical shortcoming may 
adversely affect Registry scores for our new graduates. Methods: The University 
of Pittsburgh -Johnstown RT program developed an interstate partnership with the 
University of Michigan Medical Center to provide a specialty ennchment program 
for RT students. Each RT student panicipaled in a 1-week concentrated enrichment 
program conducted by staff therapist and supervisors at the University of 
Michigan, TTie program consisted of clinical experience, lectures and information 
exchange between the students and staff. This formal emulates the principle tenants 
of the intemational enrichment program fostered by the AARC for visiting faculty. 
Following completion of the enrichment program each student was surveyed to 
identify the degree of satisfaction with the program in addressing his or her needs 
and individual goals. Results: Seven students participated in this weeklong enrich- 
ment as part of their final semester in the RT program. The response of the student 
surveys is summarized in the Table below . 
Overall Survey Questions: 

1 . The overall experience at the hospital was well organized. 

2. How did this experience affect your perception of the level of professionalism in 
Respirator^' Care? 

3. Did the RTs you encountered at the center change your expectations for your 
own career (enable you to set your own personal goals higher)? 




Question 1 




Question 2 




Ouestion 3 




Conclusion: Academic medical centers have a professional obligation to provide 
enrichment e.\penences lor RT students. This interstate ennchment program emu- 
lates the values and goals established for the AARC visiting intemational professor 
program. Our initial experience indicates that such an enrichment program is bene- 
ficial to the overall experience of the RT student. ^, 

^ OF-02-1 34 

WEANING PROTOCOL Loretta Williams. RRT. Robert Fleming, MD, Joseph 
Lucrezia, RRT, Peggy Danek, RN, Frederick Weinbaunt, MD. The New York 
Hospital Medical Center Of Queens, Flushing, New York 

Background: The RDMU was established to expedite early transfer of stable 
ventilator patients failing spontaneous breathing trials in the intensive care 
unil(lCU), The purpose of this study is to evaluate cost savings and clinical 
outcomes of patients on prolonged mechaiucal ventilation in the acute care settii^ 
of a community teaching hospital. 

Methods: A prospective study was undertaken to assess the impact of the RDML 
on ventilator liberation rale, ICU length of stay, hospital length of stay for patients 
in DRG 483, and total cost saving for the initial six month tnal period. The 
RDMU IS a 13 bed non-invasive monitored unit utilizing capnography and 
oximetry and a patient dnven weaning protocol , 

Results: There were 1 14 consecutive admissions to the RDMU in a six month 
period. Ventilator liberation rate was 61/94(64,87) for all patients entered in the 
weaning protocol. Mortality rate was 25/1 14 (21%) ICU length of stay for DRG 
483 decreased by 3 8 days, total hospital stay declined by 8.8 days, total cost 
savings was $409,500 for the six month study penod 
Conclusion: The creation of a specialized unit for weaning leads to a good 
ventilator liberation rate, decreases in both total ICU and hospital days with 
substantial financial savings. The reduction in cost is the direct result of investing 
in a full time respiratory therapist to conduct weaning This led to confidence in 
earlier transfer from ICU, ventilator liberation of pauents and earher hospital 

OF-02-1 35 

Respiratory Care • September 2002 Vol 47 No 9 


Monday, October 7, 9:30-1 1:25 am (Rooms 18-19) 

We're fighting 

for quality 



Areyou witli us? 

(972) 243-2272 

Charlotte Timon RRT- Texas Children's Hospital, Houston Texas 

Respiratory Therapists are performing in the nonlraditional role 
of assisting Anesthesiology in the operating room Texas Children's 
Licensed for 71 5 beds, is an internationally recogiuzed hospital 
Located in the Texas Medical Center in Houston The largest pediatric 
Hospital in the US. Texas Children's is affiliated with Baylor 
College of Medicine In 1997, Dr. Burdett Dunbar, Chief 
of Anesthesia and the director of Operating Room Services 
had a meeting to determine what the hospital could do to help 
Support the Depanment of Anesthesiology One of the recommendations 
was to have Respiratory Therapists in the Operating Room 
to assist the anesthesiologist This level of professional expertise 
was determined to be beneficial due to the reduced number 
of Anesthesia Residents that were currently in the program 
and the anticipated reduction in Residents in the future 

After some general concepts were established, the Respiratory 
Therapy Management team selected a therapist The Anesthesia 
Faculty then pro\'ided additional specialized training including. 
Operating room preparation, induction, intubations, intravenous 
Line placement, patient transport, and preoperative evaluations 
Upon assessment by the Anesthesia staff and the Operating 
Room Management team, the impact of ha\'ing RRT's in 
the OR was proven beneficial with improved patient care 
and turnover time As a result, the program has expanded 
to seven therapists. 


ICU: COST AVOIDANCE. Racnuel M Calderon. BS. RRT. RCP . Daved van StraJen, MD. 
Pairicia King, RN. BSHCS, Doug Padgett, BS, JelT Lewis, NHA, LVN; Ravindra Rao, MD. 
Tolally Kjds Specialty Healthcare and Depanment of Pediatrics at Loma Linda University 
Loma Linda, CA 


tn a pediatric subacute we measure quality of ventilator management by patient comfort 
and safety Additional reimbursement from third party payors covered this level of qualily. 
The une:<pccted finding was the significant cost avoidance to the medical system and 
society Methods: A retrospective chart review was done on all patients admitted from 
1995 to 2000 m a 50-bed freestanding pedialnc subacute facibty. Respiratory Care 
Practitioners play an active role in the Ql program Indicators that arc lecorded include 
ventilator care, ventilator rounds, and documentation of ventilator adjustments We discuss 
the failures and successes, learning more from our failures than our successes Failure is 
defined as a ventilator adjustment not standing on the first attempt or re-adjustment of 
ventilator settings uithin one week AJ! ventilator initiations and adjustments are tracked 
by the RCP and arc re\rewcd weekly in ventilator rounds Results: Ventilator rounds 
occur on a weekly basis vvhere fecdbacJi is given from RCPs, parents, and/or patients. As 
we identify the best practices, our theory of ventilator management evolved The results 
were compared with the number of transfers to the acute hospital with the number of 
ventilator dependent admissions 1 Cost comparison: The cost of care for initialing 
Mechanical Ventilation fMV) in a pediatnc subacute is compared with admission to the 
Emergency Room (ER) and subsequently to the Pediatric Intensive Care Unit (PICLO 
Table shows the base cost of initialing a patient on MV using physician charges and daily 
bed rates 

Cost of Care 
al Subacute 

Cost of Care 




J850 0O 

$850 00 



Room/ physician 




Daily Bed Rale 


S10134 00 



(3 days) 

12075 00 
(4 days) 

$1263 00 


S41 16.00 



ConclutioD: Quality Improvement program with failure analysis was associated with inaeased 
initiations aixj adjustments with concomitant decrease in transfers to the acute hospital 



Sally PjluLk RRCP . Rosemary Martino M.Sc. MA. S-LP(C). Mar\' Ann Near) M.Sc . S-LP(C(. 
Sandrj Gflms RRCP. Elana Aziza MHSc. S-LP(C). John T. Granion MD 
Uni\ersit\ Health Network. Toronio Canada 

Background: A iracheotomy is commonly performed in critically ilt patients to facilitate wean- 
ing, suctioning and potentially reduce upper airuay injury Once the primary respiratory problem 
IS corrected, the challenge is then lo move the patient towards decannulalion m a timely manner 
and without complications. Patients with tracheotomies provide challenges to discharge from the 
acute hospital since many institutions will not accept this more complex patient. The decision 
process on how and when to decannulate tracheotomized patients requires expertise from several 
health professionals. A mullidisciplinarv' Tracheostomy Team \Aas formalized m 1997 at our ter- 
tiary' acute care facility with representatives from Nursing. Respiralon. Therapy, and Speech- 
Language Pathology. Over time this Team has become more cohesive and systematic in its 
approach with weekly rounds and data forms thai facilitate and record joint decisions regarding 
indiMdualized management for inpatients with tracheotoimes. 

Methods: This research is adescnptive andempincal analysis of the prospectively weekly<o!- 
lected outcome data for all tracheotomized in-patients seen by the Team from 1997 to 2001. Data 
on 22V patients who received lemporar)' tracheotomy tubes were compared in one-year intervals 
from I997-2(M)I The primary outcomes for comparison were length of acute hospital stay and 
canniilation time. The secondary outcomes for companson w ere time to cuff deflation, time to 
first irachcostomy change, lime to corking, time to suture removal, mortality, and discharge dis- 
position Patient age. gender, nursing unit at time of tracheotomy insertion, height, weight, most 
responsible admitting diagnosis, tracheotomy type, reason for tracheotomy, Glasgow Coma Score 
at admission. Glasgow Coma Score at the first and last tracheotomy day. number and type of in- 
patient surgical procedures, and number and type of in-patient diagnosis were compared at base- 
line to ensure similarity. 

Results : Preliminary results from initial descriptive analyses show a pKtsitive influence on patient 
outcome v^ith Team intervention Specifically, there is an overall trend toward reducing mean 
length of acute hospital stay and cannulation time. 

Dulconies in 

Year of Tracheotomy Insertion 

neiin davsl5D) 






HiKpiul sljy 

97.1 171.0) 

96.6 (ftVO) 

108.5 (/.WO) 

112.; (90.61 



.WO (JO. /I 

-14.3 (.il-Jl 


.SI. 9 (32.61 

43 8(229) 

L'ult dcllation 

27.2 122.0) 





Time lo corking 

42.2 r27.5l 

.39.3 I27.SI 


29.1 113.7) 

47.1 (J6/) 

Discussion: Although the o\crall trend was a reduction in time measures, there was a pcnod m 1999 
and 20(10 whca- the pnmarv time outcomes increased This may have occurred due to a temporary 
decrease in Team involvement on certain uniti. Team involvement in these units resumed in the lat- 
ter pan of the year 2(X)0 and the outcomes once again appear to resume the positive trend of time 
reduction in year 2001 , Inferential analysis will be completed and results presented in yearly inter- 
vals along with a discussion of possible confounding factors. The majority of these outconw data arc 
either interval (i.e. lime in days) or nominal (i.e. dischargedisposition). therefore distributions will be 
tested for normality and then ANOVA will be performed to compare multiple yearly time penods. 
Conclusion : This preliminary data suggests benefits from a cohesive and structured team approach to 
the care of in- patients with tracheotomy mbes. The benefit of reducing cannulation time v. ill likely 
influence a decrease incost of service provision along with an increase in overall palieni quality of 

'■f^ OF-02-166 


Respiratory Care • September 2002 Vol 47 No 9 



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MONDAY, October 7, 9:30-1 1 :25 am (Rooms 20-21 ) 


Timothy R. Myers BS. RRT and Thomas J, Kallstrom. RRT. FAARC for the American 
Respiratory Care Foundation. American Association for Respiratory Care & the Environ- 
mcnial Protection Agencies Indoor Division, Dallas, TX & Washington D.C. 
Introduction. There are various approaches to asthma care and education of pediatric 
patients once they arrive at an acute care facility Our particular interest was how respira- 
tory therapists in pediatric hospitals and aduli/pediatric (non-traditional) hos- 
pitals manage asthma-related care and education to children Our primary objective was to 
benchmark and compare current initiatives and educational in both traditional and non-tra- 
ditional pediatric asthma settings. Methods. We designed a needs assessrneni instrument 
that sought information about how respiratory care departments practiced inpatient asthma 
care and to identify and caicgori/c asthma education initiatives. For centers that identified 
pertorming education imttaiives, we also queried them on implementation of indoor envi- 
ronmental tngger education. This tool was distributed to 500 hospitals offering pediatric 
emergency or inpatient services. Results. 133 hospitals (26.6'7r) responded to the survey. 
An additional 27 i5'^ ) were eliminated, as they responded to providing neither pediatric 
inpatient nor emergency services. The majority of responding centers (GS*?!-) were located 
in urban areas, reported to be non-traditional pediatric hospitals (4l.7^r). and considered 
themselves academic/teaching facilities (62.5'7c). Specific hospital areas that reported 
treatment and / or education initiatives for pediatric asthma patients were as follows: ED 
=90-7*"/(, inpatient =83.79f, and outpatient =60.5%. On average, less than 50*7^ of the 
responding hospitals were currently using prolocolized care. Approximately 1/3 of the 
respondents were developing hospital-based protocols and 24.6% were developing ED 
based protocols. Across the board for all hospitals, the RT was responsible for asthma 
education (W,2%). followed by the RN (My.- ). physician (5\.^''/c), and pharmacist 
( 17 (I'f ) In adult/pediatric hospitals. 52' vol respondents spend < I -hour on patient educa- 
tion, while in pediatric hospitals. 71% of the respondents spend between 1-5 hours. The 
table below lists respondent percentages for key initiatives, and the comparative p-values 
determined by Chi Square Analysis. 

Breakdown Overall 




liseofEDProCocol 45,49; 

4 1 ", 



Use of Inpatient Protocol 4y.6'/t 


74 :'; 

<0 00l 

Trisper Education "^.IST^ 

')2 s'l 

•Jh S'i 


Staff is Trained 22 f, 


5: y: 


Staff \sthma Competency Tested M)''i 

IS 9'; 

IS ^'; 


Interested in Toolkit 84.7'* 




Conclusions: A significant difference exists between traditional and non- traditional hos- 
pitals in treating pediatnc asthma with protocol therapy. While the majority of responding 
hospitals provided asthma trigger education, respiratory care staff training and 
competency occurred less than a third of the time. Based on the results of this study, fur- 
ther uork on the development of asthma protocol therapy, staff training and competency 
testing needs to be done. 


VIET NAM. 1^ Thi Tuyct Lan. The University of Medicine & Phannacy. and U Thi Thu Huong. 
Nhan Dan Gia Dinh Hospital — Ho Chi Minh City. Viul Njin Introduction B) definilion ut GINA- 
2002. patients with cough-vanant asthma have chroniL mugh as their pnncipal syiiiptoni. Frequently 
the cough occur> at night so that evaluations dunng the day can be normal , ' There are 3 
recommended ways to diagnose the cough-vanani asihnia documentation of variability in lung func- 
tion or of airway hyperresponstveness and search lor sputum eosinophils ' Because of the limitations 
of these three methtxis and the lack of facilities in Vielnam. we use the niclhi>d ot spirometry with 
bronchixlilator test to delett cough-vanant asthma. Tliis melhinJ has lound wnlespcad acceptance for 
use in a-sthmauc patients over 5 years ol age. but iLs role in cough-\anjjii asihma is ni>t well 
documented Materials: Among 142SpauenLs who came to our pulmonary tunciion labonilnry lo 
have spiroriieUnc lest done, with various purposes, from November 2001 lo Apnl 201)2. 101 patients 
have been diagnosed as having cough-vanant asthma_ Those patients have chronic cough, with or 
without chcs tightness but no wheezing The spu'omelnc tests were adhered to the method of ATS. 
1994 .■Tliebri>i.hodilati)r lesi was performed for all these paUentsinlhe fir^t Ume A second spironiel- 
nc test wa-s perlomied alter 2 weeks of ueatment and every 3 months later, if possible The diagnosis 
of variant-cough asthma by spirometry was made when at least a 12 percent improvenieni inFEVtor 
15% increase in PEF{on flow-volume curve), after inhalauon of 200 mgr of salbuiamol sulfate or in 
response to a tnal of glucocomcoid therapy. PalienLs who stopped coughing after glucorticoid 
trealmeni with norma! spiromeinc recordings, before and after the treatment, were also diagnosed as 
cough-\ananl ashma Results & discussion: The result of 103 pabents showed that there are 3 types 
of spiromeinc responses 

Table I I hree l\ pes i \\ spiromeinc responses in cough-variant asthma 
Types of spirometric responses 

1 Posiuve response lo shun acting bronchodilator 87 84 

2, No immediate rcsptmse to short acting brochodilator 

but improvement on spiromeinc recordings after a tnal 

of glucoticoid therapy 8 8 

3- Nomial spirogram before the treatment and 

no improvemenLs on spirometnc recordings, but improve 

clinically after a uial of glucocomcoid therapy 8 8 

Thus in our study, the spirometry is useful in diagnosis of cough-vanant asthma up to 927t of cases. 
Those patients have been diagnosed as tonsiihiis. sinusius. phar\ngins, or chronic brochitis and have 
been treated inappropriate l\ uith successive courses ot antibioin.s and cough medications They have 
suffered the cough trom 2 uccks to 33 years belore the diagnosis of cough-vanant asifima is made. 
Bui caution musi be made for other differential diagnosis as acuve tubereulosis. gastrt>esophageal 
reflux, use of ACE inhibilor and psychologic cough. With the diagnosis as eough-\ anani asthma and 
appropnate asthmauc treatment, the symptoms generally disappear after 2 weeks ot treaimenl. the 
qualitv of life of palienLs usually markedh improved The high pt^siuvc result ol spironietr. in cough- 
vanant asthma in Vietnam ma\ reflect a reality that the diagnosis ol Lough-vanant asthma have been 
delayed for a substantially long time. Conclusion: Although the spiromelrv vv iih bronchcxiilator test is 
not widely recommended as a mean lo detect cough-vanant asthma w e found that it is a very effecUve 
method in Vietnam. The result of 929( of patients with cough-vanant asthma have had positive 
response on spirometnc recordings in Vietnam may reflect the great delay in making the diagnosis of 
cough-variant asthma in this country. We suggest that the spirometry with bronchodilator test should 
be recommended as a tool in diagnosis of cough-variant asthma, especially in developing countries. 

1 . Claude Lenfant - Global strategy for asthma management and prevention: Diagnosis and classifiac- 

2. ATS Statement -Standardization of spirometry- 1994Updaie. Am J RespirCrit CareMed, Vol 
152 pp 1 107- 1136, 1995 OF-02-060 


Cheri A. Duncan RRT. RCP: Grace Hernandez RRT, RCP; Erika 
Abmas RRT, RCP; Mark Millard, MD, Baylor Asthma and 
Pulmonaiy Rehabilitation Center, Baylor University Medical 
Center, Dallas, Texas 

BACKGROUND: Asthma is the leading chronic medical cause 
of absenteeism in school. Educational intervention can increase 
the efficacy of disease management. " Rules of Two"™" (R02) is 
a paradigm for assessing asthma control and the need for anti- 
inflammatory therapy. This study describes the outcomes of 
educating asthmatic school aged children on R02 during a one- 
day asthma camp. METHOD: A RRT first presented a 1 5-nunute 
educational session about peak flow monitoring (PFM) and R02. 
The children were reminded of these topics throughout the day's 
activities. RESULTS: At the end of the camp the children were 
asked to answer questions regarding R02, with 82% (41 
children) able to answer all questions correctly. Two weeks 
following camp a telephone survey (32 families contacted) was 
performed; 18 (56%) recalled R02 correctly. 21 (66%) were 
continuing PFM, and 1 1 (34%) reported new medication 
prescribed as a result of information learned at camp. 
CONCLUSION: Children can be taught R02 in a one-day 
asthma camp with a resulting improved knowledge base and 
upgraded medical management. 


ASTHMA? Ten\ S. LeCrand. PhD. RRT and David C. Shelledy. PhD. RRT, University of 
Texas Health Science Center at San Antonio. TX. 

Background: The Borg dyspnea scale is frequenUy utilized dunng asthma exacerbations to 
quantify a patient's perceived level of dyspnea. The Borg scale was designed in l%2 to rate 
perceived exertion during exercise and was modified in 1982 to measure a padeni's perceived 
intensity of dyspnea using a I2-poimscale- Respiratory therapists (RT) are trained to approxi- 
mate the seventy of their patients" symptoms based on objective measures of physical assess- 
ment There is a subpopulation of asthma patients whose perception of dyspnea is blunted, and 
these patients ha\ e been shown to be at greater risk for death from asthma. Identification of this 
subpopulation ma\ enable them to become more aware of escalating asthma symptoms. Objec- 
tive; To dctcniiinc if patients' percei\ ed dyspnea is reflected by the respirator> therapisLs" clini- 
cal assessment of symptom seventy in moderate to severe asthmatics. Methods: Asthma symp- 
tom scores and Borg dyspnea scores were obtained from subjects upon enrollment in an asthma 
disease management study (n=l 16). The Borg scale is shown in Figure 1, The asthma symp- 
toms severity score (Figure 2) is assigned by the RT and is based upon a brief physical exami- 
nation that includes pulse oximetry, chest auscultation, and the best of three forced vital capac- 
liy maneuvers. Results were determined by Pearson paxluct- moment correlation with P < 0.05 
being significant. Results: There was a modest correlation (r=t).30. P < 0.05) between subjects' 
Borg scores and symptom scores assigned by the RT. Based on these results, 9'7( of the 
\ariance (coefficient of determination, r) in the Borg scores was predicted by symptom scores, 
indicating that 9 1 % of the lime, patients' Borg scores do not correlate with the severity of their 
symptoins as assessed by the RT. Conclusions: Patients who have been classified as having 
motlerate to severe asthma are those who experience daily or continual symptoms, have 
liei|uc[it nocturnal symptoms, and routinely have peak flows measuring below SC^ of 
preilicted v;ilues with significant variability on a day-to-day basis. Thus it is not surprising that 
such patients become so accustomed to experiencing asthma symptoms that they do not always 
realize when they are lulling into the yellow zone of their action plans. If these patients were 
more cognizant of how their symptoms feel when they arc beginning to worsen, as evidenced 
by physical assessment and pulmonary function testing, they may realize sooner the importance 
of seeking medical care in a timely fashion. While there is a modest correlation between Borg 
scores and RT assessment scores, these results should be interpreted cautiously due lo the vari- 
ability inherent in clinical assessment. 

Table I, Borg Dypnea Scale 

nothing at all 6 between 5*7 
0.5 just noticahle 7 very severe 

1 very slight 8 between 7 & 9 

2 slight 9 very, very severe 

3 moderate (almost maximal 

4 somewhat se\cre 10 maximal 

5 severe 

Table 2. Symptom severity score 

no symptoms 

1 mild symptoms 

2 moderate symptoms 

3 moderately severe symptoms 

4 severe symptoms 

5 very severe symptoms 




Monday, October 7, 9:30-1 1 :25 am (Rooms 20-2 1 ) 

U-Grand.PhD.RRT . Gabnella Nunc/. CRT. Jcnnilcr Sikkcma. CRY. aiid David C. Shclledy. 
fnil). RKT. University ot Tcx;ts Health Science Center ai San AnH>nu>. TX. 
Backgn)und: A variety of a.NNCSNnicni tiK>K has been dcvekipcd to qiuiniily well-hciny n:laicd 
to a s[X*citic diM.'aNe(the Si. GeorycS Respiratory Quest lonnaia*. SGRQ). quality of lile.QC^L 
(the Medical C)uIconie,\ Study 3(viicni Shorl Fonii Health Survey, Sh-.16), aiid pcrveived dysp- 
nea (the Btirj: scale). By cxanuniiii; scores obtained with these instninK'nls, it may be possible to 
dettvl a correlation between perception of welt-being and numbers of inpatient hospital days 
( IPH ) and emergency dcp;irtment \ isits (ED), Objective: To examine the relationship bctwcrn 
asthma symptoms, quality of life, and hospital admissions in nwKlerate to seven: a.sthnia. Meth- 
ods: SCiRy. St*-.^fi, and Bor^ scores werv obtained fnim subjects with nwKlerate to sevea* 
asthma upon enmllment in an asthma disease management study (n=l-W)). Scores were corre- 
lated \\ ilh numbers of ED visits and IPH days during the 1 2 months prior to enmllment in the 
study The SGRQ and SK-.Vi instruments ;ire widely used and have been subjected lo Viilidily 
and reliability lesling. The pre.sent fonnof the BorgscaIe(a 12-point scale used by [wtienLsto 
rate their pere'eived level of dyspnea frum "nothing at air"Io"ma.\imal"')hasbeen in use clini- 
cally since 1982, The SGRQ employs 3 domains: Symptoms (SGS), covering severity and fre- 
quency; Activities (SGA). covering activities that cause or iirt limited by dyspnea; and Impacts 
(SGI), covenngstx'ial function and psychological disiurb;mce resulting fmm airways disease. 
The 3 domains are compiled to yield a total score ( SGT). Higher scores indicate diminished feel- 
ings of well-being. The SF-36 covers S domains, including physical functioning (PF), stvial 
functioning (SK). w\c limitations due to physical (RP) and emotional pmblems (RE), mental 
health (MHi. energy and vitality (VIT). pain (P). and general health (GH). Higher scores reflect 
better quality of life. Results were deleniiined by Peiirson prxiduct-moment correlation with P < 
O.OS being significant. Results: An increase in ED visits correlated with an in SGS. 
SGI. and .SGT scores (r=^) 27 for each), indicating a decline in general well-being. An incre*ase 
in IPH days alsore*sulted in increased SGI ir=0,I8) and SGT (r=<).2()) scores. Decreased ED vis- 
its and IPH days were associated with increased GH scores iM>,24i. indicating higher QOL. 
and IPH days exhibited the same negative correlation with PFand RH score's (r^).20 and 0,23, 
respectively ). Interestingly, numbers of ED visits and IPH days were not related to SGA. P. VIT. 
SF, MH. and Borg score's. Borg scores exhibited a significant correlation with SGS. SGA. SGI. 
SGT. PF. RP. P. SF. RF^. and MH. as expected, but did not have any relationship to numbers of 
IPH days or ED visits. Conclusions: There appears to be some relationship between the 
frequency of admissions and patients" perceptions of symptom seventy and frequency, as well 
as the impact of their disease nn stxrial function and psychological factors. Not surprisingly, bet- 
ter perceptions of qualit\ of life in the arenas ol ph\MLal lunLimn. general health, and role limita- 
tions due to emotional pmblems were refiected m fewer adniissiitus. However, there was no 
relationship between admissions and activities that cause or are limited by dyspnea. Regardless 
of role limitation due to physical problems, pain, vitality level, mental health, or Borg scores, 
there was no change in the number of admissions. The re'sulis suppt)rl the fact that limitations 
and the impact of asthma on activities of daily living does not always result in patients* seeking 
medical care. This finding may be a factor in the greater nsk for astlima death that is seen in this 
patient population. OF-flP-l 1 9 


Janios H. Martin. RRT . Susan R. Oprinc, RRT. Rofx-n (". Cohn, MIX Dcparuiicnis of 
Pfdialrics, and [*uliiionary Services, MclniHcallli Medical Center. Cleveland. OH 

INTRODUCTION: Many fomis iit delivery devices ate available lor ihe inhala- 
tion route. Confusion on proper Inhalation leehnii|ue may aflcci medication deliv- 
ery. Multiple inhalations from se\cr;i! tleviees have als(/l>een shown to reduce 
compliance. Our PACTC^Iiiiic atldiessts the issue ol ;ulministration and adherence 
with therapy. l*or routine Iherapy. palieiils can Iv piescnlvd up to S puffs/day 
frtMii multiple MDl's. To help witli compliance our patients were giving the option 
of liikingone inhalation BID with the Dry Powder Inhaler (DPI) Adviiir Diskus. 
An eight-step approach to Diskus atlministration similar lo the MDI was devclopeil 
to determine if the Diskus is a suitable altcmalive to MDI. METHODS: Data 
from twelve astlima patients average age 10.2 years (range 7- 1 6), •■) male/3 female. 
5 African American/4 Caucasian/-^ Hispanic, seen in our PACT clinic were 
aniilyzed. All patients demt)nstratcd iheir MDI technique a median of 5 times O- 
12) before the introduction of the Diskus, Tliere wasanaverageof 2{ 1-4) months 
between initial Diskus insliiiction and follow up evaluation. Administration 
technique was tested for both the MDI and Diskus using a placeK^) if necessary. 
After allowing the palieni to demonsiralc llieir technique, a thorough review and 
demonstiLiiion \^as [vrrnniicd, RESULTS: ^*/l2 (75'; ) palients perlbmied all S 
steps of liie Diskus conectly, where as .VI 2 (42'^/^ ) behnc and 4/12 (337f) after 
Diskus introduction perlbmied all S MDI step successfully. Although not 
statistically significant {p>().2.S) failure to perfomi a slow deep breath following the 
actuation of the MDI increased from 4/1 2 ( ?>}% ) to 6/1 2 (50%) following the 
Diskus introduction. 

■ MDI Pre DlttkuB 
MDI Post Oskus 

■ DISKuft 


CONCLUSION: The Diskus delivery system is easy to teach and easy to learn. 
Our patients performed the technique wiUi far fewer reinforced steps than the MDI. 
A rapid inspiration required for DPI may have contributed to a more rapid inhala- 
tion seen in the MDI group following Diskus introduction. Continual evaJuation 
and reinforcement maybe necessary to ensure proper inhalation for each delivery 
device. OF-02-116 

MS^ RRT . Kaiser Permanenle, Portland, Oregon. Background: Following positive results of 
a RCT pilot project, our case management program concluded the llrst year m 2001. Four ER's 
were target for outreach to asthma & COPD patients, along with physician referrals. Two trained 
RCPs were ulih^ed for 1,5 FTEs.The interventions include phone contact. PFTs, office visits with 
the manager Plus follow up wiih the patient and pnmary care provider (PCP). Our goal 
wa.^ to opiimi/e management of palients with adult asthma and COPD according to the KPNW 
Regional Clinical Practice Guidelines by impro\ing our patients' state of health, well being and 
satisfaction and to efficiently utilize resources. Method: Program evaluation included reviewing 
entry and exclusion cnteria. procedures for screening & managing patients, discharge cntena. out- 
comes measures. PCP & patient surveys, cosi measures, and learning's & systems barriers, Uli- 
hzalion data was relnevcd from our electronic medical record lEMR). Uttli/ation data includes 
hospitalization. ER and urgent care/unscheduled visits, plus docior office visits. Cost measures 
utilized national average costs for ER and hospitalizations. Results: A total of 901 patients were 
screened with 450 receiving outreach interventions Enrolled palients totaled 319 with 164 asth- 
matics and 155 COPD, Patient satisfaction and PCP surveys showed positive feedback. ER uti- 
lization decreased 56*^. hospitalizations decreased 39*^. urgent care visits decreased 52'7(. and 
docior office visits decreased 32%. Cost savings calculated at $106,874. 

Respiratory Utilization & Costs before and after enrollment in RCP Case Management 
Enrulled ER before ER after hospital hospital UCC UCC 

before after before after 







total: 319 305 1.34 

Aslhma costs $25,620 $6,720 $35,503 

costs $53,802 $29,988 S29I.762 

Savings difference before and af ler ma nagement 

Aslhma = $47^27 S I «.9(M) $2 1 .848 

COPU= $134,410 

total = $181,957 

$ 1 87..3fW 

23.814 $104,458 






56 27 

$1,494 COPD 

WdLV & Bcnctiis = 
Program Savings - 



Costs = 

AsthmiiF.R AsthmaHosp 
$210 $2,731 

COPD ER COPD Ho% Clmic visit 
5294 $3,602 $65 



Conclusions: Adull asthma and COPD case management provided by respiratory care practition- 
ers is both effective in improving self- management and care satisfaction by palients and in 
decreasing utilisation of scheduled and unscheduled healthcare visits. Measuring outcomes of 
both customer satisfaction and cost savings are strong motivation to health care systems to provide 

case management for this population, ^ 

^ OF-02-120 

A ainical Asthma Score (CAS) PredlcU Need For Admission of Asthmallc 
Palients from a Pediatric Emergency Department, Perry Picchi RRT. Katie 
Sabalo RRT MS. Jeanetlc Abbclrn RRT MS, Mary Rutherford MD 

Asthma is the leading diagnosis for visits to the Children's Hospital Oakland 
Emergency Department (ED), accounting for 1 3% of all ED visits. We developed a tool, 
the CUnical Asthma Score (CAS); a modificaUon of the Woods Downcs asthma score, to 
objectively evaluate our asthmatic patients" degree of respiratory distress. This scores 
evaluates three aspects of 3 patient's respiratory distress: ( 1 ) degree of wheezing, (2) 
degree of retraction and/or flarmg, and (3) degree of dyspnea Each category is given a 
score of 0-3, so the total score ranges from 0-9, with 9 bcuig the worst score. 

The CAS has allowed the ED caregivers a sunple system for identifying degree of 
respiratory dysfunction and for standardizing treatment The purpose of this study was 10 
evaluate the usefulness of the CAS ui ptcdictiug need for admission to the hospital from the 

Benvecn Sept. 1 . 2001 and Feb. 3, 2002 we used the CAS to evaluate asthma 
seventy in patients seen in our ED, and correlate it with admission status. Patients were 
first scored by a nurse in the Triage Room, then were examined by the ED physician. The 
ED physicians were unaware of the CAS, and subsequent decisions lo admit Ihe patient to 
the hospital were made independently of the CAS. 

We analysed the admission rales of all asthmatic patients seen in the ED during 
the study period for whom a CAS was assigned in the Tnagc Room. The rales of adnussion 
were calculated for each score, so that we could identify predicnve "break pomts" m the 

During the study period. 306 pHtienLs ber*een the ages of 2 and 1 7 were seen m 
triage for asthma. Of these, 47 (26%) had scores of 0-2, 182 (59%) had scores of 3-6. and 
77 (25%) had scores of 7-9 As shown in the Table, scores of 0-2 predicted a low risk for 
subsequent adrrossion, while scores of 7-9 predicted a high risk for subsequent idrmssion. 




Kot Admined 





1 1 (23%) 
78 (43%) 
53 (69%) 

36 (77%) 
24 (31%) 


The CAS is a relatively reliable predictor of nsk of adrrassion from the ED for 
pediatric pauents with asthma, if their scores are at the low (0-2) or high (7-9) end of the 
sjjeclrum. For those palients with middle scores (3-6). the nsk of admission is 
approximately 50%. We conclude that the CAS is a u.seful tool for predicting need for 
adnussion at the tune of mage. We speculate that the addition of other paramclers. such as 
pulse oximetry and peak expiratory How. will hirther improve Its predictive value. 


Respiratory Care • September 2002 vol 47 No 9 



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Use of a Clinical Asthma Score (CAS) as the Initial Step in an Asthma 
Treatment Algorithm in a Pediatric Emergency Department K^Iis 
Sabatc MS RRT . Perry Picchi RRT. Jeanctte Asselin MS RRT. Mary 
Rutherford MD, Children Hospital Oakland, Oakland California. 

Background: Objective assessment of patients with asthma in the Emergency 
Department (ED) is difTicult. To address this problem, we developed a Clinical 
Asthma Score (CAS, Table 1) a modificahon of the Woods Downcs asthma score' 
for assessing the seventy of asthma in patients over the age of 2. We also developed 
an Asthma Treatment Algorithm that utilized the CAS as the first step in determining 
initial trcatn:ent. The algonthm stipulated that patients with CAS i 6 be immediately 
placed on a one hour lOmg dose of continuous albuterol. We performed this study to 
( 1 ) determine the concordance between initial evaluations with the CAS, and (2) to 
evaluate degree of compliance with the initial phase of the Asthma Treatment 

Methods: Between Sept. 1, 2001 and Feb, 3. 2002, we used the CAS to evaluate 
asthma seventy in patients seen in our ED. Patients were Grst scored in the Tnagc 
Room, again in the ED, and fmally examined by the ED physiaan. To evaluate 
agreement in CAS scoring between the Tnage and ED evaluations, we collected data 
forms on patients seen in the ED dimng Ihis 6 month period. To evaluate compliance 
with the Asthma Treatment Algonthm, we compared initial treatment with the CAS. 
Results: Dunng the study period, 268 patients were scored with the CAS m both 
Triage and in the ED. Table 2 shows the concordance between the Tnage and the ED 
sconng. Scores were identical in 78 (29%) of the patients, within 1 pomt in 165 
(62%). and within 2 points in 218 (81%). 135 (90%) of the 150 patients with a CAS 
2: 6 received continuous albuterol as their first-line therapy 
Table 1 Table 2 



Total panems 

Identical scores 
Scores within 1 pomt 
Scores within 2 point 


78 (29%) 

fk; FCt) actions 

r« wtwecng 





Norma eoMfv 


Inso a Ltp. 






Conclusion; ( 1 ) The CAS is a simple and reliable score which is highly reproducible 

(Sr/o scores within 2 points) for panents who have serial evaluations. (2) Utilizing 

the CAS as the initial step in an asthjna treatment algonthm leads to a high degree of 

success (90%) in immediately beginning continuous albuterol in patients with severe 


I , WooiiDW, Dowries JJ, Leeks HI. A clinical scoring system for the diagnosis of 

respiratoryfailure. AmJDis Child 1972; 123:227-228 


Respiratory Care • September 2002 vol 47 No 9 

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Monday, October 7, 2:00-3:55 pm (Rooms 18-19) 













Jolvon P. Milchcll Ph.D . Sara-l.ou Billed. Calhy C. Doyle B.Sc. 
and Mark W. Nagel HB.Sc 
Trudell Medical Aerosol Laboralory. London. Canada 

VHCs are recommended for with pressurized metered-dose inhalers (pMDIsI 
for Ihose palienis who may delay the onsel of inhalation after pMDI actuation. A 
draft CanadianiC.AN/CS.A) Standard on .Spacers and Holding Chambers (expected 
publication. 2002 1 has recommended that in vino performance testing be 
undertaken with a 2 s delay to simulate this behavior. We compared the 
performance of two similar sized VHCs ( AeroChamber Plus'*c. Monaghan Medi- 
cal Corp.. Plailsburgh. NY and PrimeAirc®. Thayer Medical. Tucson. AZi (n = 4 
devices/group) with a 2 s delay between actuation and sampling into an Andersen 
8-slage cascade impacior equipped with USP Induction port. Each VHC was 
washed with an ionic detergent, nnsed and dnp-dried to minimize the influence of 
electrostatic charge. The impactor was operated at 28. .1 ± 0.5 L/min in accordance 
with<601> of the US Pharmacopeia, representative of the inspiratory flow rate 
range seen in adult patients. A purpose-built apparatus enabled the delay interval 
to be reproduced to within 0.1 s. .5-doses of fluticasone propionate (FP) (Flovent® 
1 10. GSK Canada Inc.l were initially delivered from a pre-primed and shaken 
pMDI canister at ."^O-s intervals via the VHC into the induction port of the 
impactor. The induction port and stages of the impactor and the VHC were subse- 
quently assayed for FP by HPLC -UV spectrophotometry. 

Measurements of fine particle dose (FPD - particles < 4.7 mm aerodynamic diame- 
ter) and total emitted dose (TED) are summarized in the table. Fine particle 
fraction (FPF) is the ratio of FPD/TED, expressed as a percentage. 


AeroChamber Plus™ 








9.V6 ± 2.7 

96.3 ±0.6 

mean ± S.D 
As expected, both types of VHC largely eliminated coarse particles, with similar 
values of FPF for this formulation (p = 0. 10). However, both TED and FPD from 
the AeroChamber Plus^f r VHCs were greater than their equivalent values from the 
PnmeAire® VHCs [un-paired t-iest. p< 0.001]. 

Tlie mtroduclion of a delay to mimic the uncoordinated patient resulted in signifi- 
cantly reduced output from the PrimeAire® VHC. The clinical 
significance of these results remains to be explored. OF-02-006 


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Jolvon P. Mitchell Ph.D . Sara-Lou Bates. Cathy C. Doyle B.Sc. 
and Mark W. Nagel HB.Sc 
Trudell Medical Aerosol Laboratory, London. Canada 

VHCs are recommended for use w ilh pressurized metered-dose inhalers (pMDIs). 
especially with small children whose coordination between pMDI actuation and 
the onset ut inhalation may be poor. We compared the delivery of a bronchodila- 
tor (CFC- Ventolin". GSK. 90 pg/dose albuterol) via two VHCs (AeroChamber 
Plus'" with medium mask. Monaghan Medical Corp.. Plattsburgh. NY. (volume = 
149 ml)i and OptiChamber^ Advantage. Respironics*. Pittsburgh. PA (volume = 
218 ml )) (n = 5 devices/group). We measured total emitted dose (TED) and fine 
particle (< 4.7 mm aertxiynamic diameter) dose (FPD) at 4.9 and 12.0 L/min. rep- 
resenting inspirators flow rates achieved by small children, by means of a low 
flow Marple-Miller cascade impactor equipped with USP Induction port, follow- 
ing compendial procedures. Each VHC was washed with an ionic detergent, rinsed 
and drip-dried to mmimize the mfluence of surface electrostatic charge. 5-doses of 
medication were delivered at 30 s intervals from pre-primed and shaken pMDIs. 
The induction port and stages of the impacior and the VHC were subsequently 
assayed for albuterol by HPLC-UV spectrophotometry . Measurements of fine 
particle dose (FPD - particles <4.7 mm aerodynamic diameter) and total emiiied 
dose (TED) are summarized in the table. Fine particle fraction (FPF) is the ratio 
of FPD/TED. expressed as a percentage. 

mean ± S.D 

4 1 IJmm 

12.ni7mm I 

Plus" VHC 

,^d\anla2e VHCs 

Plus" VHC 

Advantaee VHCs 

TED (Jig 1 

24.3 ± 2.0 

ISO ±3.6 

32 4 ±6.0 

25 5 ± 1.9 



17.8 ±3.4 

31.8 ±5.9 

25.2* 19 


97.5 ± 1 

99.1 ±3.1 

98.1 ±0.4 

98.7 ±0.1 

As expected, both types of VHC largely eliminated coarse particles, with values of 
FPF > 96'7r at either fiow rate. How ever, both TED and FPD from the AeroCham- 
ber Plus'" VHCs were significantly greater than their equivalent values from the 
OptiChamber'^ Advantage VHCs (un-paired t-test. p < 0.4! ). The larger volume 
of the OptiChamber*' Advantage VHCs was not associated w ith improved deliv- 
ery, indicating that other considerations such as inhalation valve design as well as 
internal geometry may be important. 


TimConlin MS RRT. St. Vincent Hospital. Indianapolis. IN 

Background: FYoper inhalation technique when using inhalation devices is important for 
deposition of medication to the lungs. A common misconception among patients is to 
breathe hard and fast to get medicine in the ainvays. Recommended inhalation rate for 
MDI's are 30-60 L/Min ( I j.Children who use metered dose inhalers often inhale ttxi 
quickly, but there hasn't been a simple way to measure actual speed of inhalation, A 
device called the In-Check DIAL is now available that measures inhalation fiow rates for 
patients using inhalers. 

Method: Students who were enrolled in an asthma education program in several schools 
were assessed inhalation tlow rates. Students who said they currently use or have used a 
metered dose inhaler were tested pnor to the education sessions. Using the In-CTheck 
DIAL. 3 measurements w ere recorded for each student asking them to "pretend this is a 
metered dose inhiUer". and inhale "just like >ou do when you use your inhaler". Average 
\ alues were obtained for each of the students. 

Student's Peak Inspiratory Flow 


m I 

Utar. |Mr nanut. (L«*i) 

Re.sults: 78 students in grades 2-5 were tested. Only 8 students aehie\ed inspiratory rates 
of 30-60L/min. 70 recorded higher le\ els. with 48 studenLs at 1 20 L/min or gieater. 
Conclusion: The niaiority of children in this sample inhale loo when using a metered 
dose inhaler Tltc use of the In-Check DIAL can be a useful tool to help assess inhalation 
rates in children 

1 Canclh HJ, Kanner RE Optimizing Deposition of Aerolized Drug in the Lung: A 
Re\ ievv . Medscapc Respirator\' Care 3(1). 1999 




Monday, October 7, 2:00-3:55 pm (Rooms 18-19) 


Robert S. PikarNkv. BSRT . Ru!,sell Acevedo. MD. FCCP. Charles Roman. RRT. Wendy 
Fascia. RRT. Trace) Farrell, RRT. Crouse Hospilal. Syracuse. NY. 

Pl'RPOSE: Betj;-ag(mist Racemic Albuterol has been used extensively in ihc pertnrmance ot 
pre & ptisi bn>ncht)dilaior studies in the pulmonary turKliitn laboratory. This study evaluated 
the safety and efficacy ot timed nebuli^^ation of the two dosages of Levalbuteml (Sepracor Inc. 
Maribort>ugh. MA) as compared to Racemic Albuteail (Dey. Napa. CA) with the use of the 
AcruEtlipsc Brtiath .■Actuated Nebulizer! B.\N| (Monaghan Medical Corp, Plattsburgh. NY,). 
METHODS: A consecutive, non -randomized, mosilv COPD population in = 93) receiving 
pre & post bronchodilator tesimg in our Pulmonary Function L^b were studied. Two different 
Levalbutcrol medication dosages v^ere administered; 0.63mg Levalbuteail UD or 1 .2,Smg UD 
Levalbuteml. The Racemic Albuterol dosage was 2.5mg LID, AH 5 minute timed aerosol treat- 
ments were administered using the BAN with an oxygen flow rate of 8L/min, The Sen- 
somiedics Vmax 22 Pulmonar> Function System was utilized to measure both FEVl and 
PEFR. A standardized subjective questionnaire to deteniiine side effects was completed. 
RESULTS: The table shows the Levalbuterol and Racemic Albuterol dosages, mean '"/i 
change of FEVl and PEFR from pre-treatment to 10-minute post trejtmenl. administration 
time, tremulousness and increase in heart rate. There was no significant difference in % 
change in FEVl or PEFR. There was a significant increase in heart rate with the l,25mg Lev- 
albuterol UD group (7.2 vs. 3.4. p<.05*; 7.2 vs. 2.2, p<,Ol**). There was no difference in res- 
piratory rale, tremulousness. or nausea. 

Nebulizer (nl 


% Change 

% Change 





Levalbuterol (38l 

0.6?ni2 UD 






Levalbuterol (291 

1 Z.^mgUD 






Racemic .\lbuterol (261 

2.25mg VL 




T T** 

CONCLl SION: Five minute timed administration of Levalbuterol and Racemic Albuterol 
using the BAN was equally efficacious and had similar safety profiles. The change in FEVl 
and PEFR are consistent with our mostly COPD population. The increase in heart rate was 
greatest with the Levalbuterol 1 .25 mg dosage. 

CLINICAL IMPLICATIONS: Five minute timed administration of Levalbuterol and 
Racemic .Mbuterol using the B.AN is a safe and efficient alternative to the use of small volume 
nebulizers. Additional caution should be taken when administering Levalbuteml at the 1 .25 
mg dosage utilizing the BAN in cardiac patients. The efficiency of timed aerosol administra- 
tion could have significant impact on resource utilization while maintaining the quality of 
aerosol delivery . This may be one of several strategies to address the problems of Respiratory 
Care staff shortages or high seasonal effect in the acute care facility 



bri':a TH a(tuatf:d nebulizers 

Robert S. Pikarskv. BSRT . Russell Accvcdo. MU. FCC:p. Cntusc Hospiul. Syracuse. NY, 
PURPOSE: The Rcspiraiorv IX-partmcni converted from the Airlife Misty-Ncb iSVN) (Allegiance 
Heiilthcarc Corpitralionno the ,AcmE*.-lipsc Breath Actuated Ncbuh/er ( BAN ) ( Monaghan Medical Corp. 
PlalLsburgh. N. Y ), Tins study explores ihc clinical and cconumic impact of these inicrvcnuons. 
METHODS: PaUcnLs capable of pcrlorming aerosol tlierapy by mouthpiece wen: converted to BAN. All 
aerosols treatiiKoLs. including bieukthnmgh ireutmcnLs. delivered between 7/1/0! and 2/28/U2 were 
recorded. Fifty-four percent of the nebulizepi pun;hascd dunng this period wen: BAN. The S,6-minute 
tiniesaving of llie BAN over the SVN was from our previous pilot study' The FTE average cost 
(sulary/benefiLs»= $2().25/hr ITie average trealmcnts per piUient - day (4 40) were delemimcd from the 
ireutnient reconls. Each patient received an average of 2,5 nebulizers during their admission 
RESULTS: Economic Impact: The table shows the loial number of treaimcnls with csumaicd iime,sav- 
ing of 0.6 FTE over the 8-monlh period, or 0.9 FTE annualized ($37,746). Total number of nebulizers 
used was estimated ai 1.359, 53.8% were BAN, The increase cost of the BAN was $4,153. Overall sav- 
ings was $33,592. Resource Utilization: Compared with the same months studied of the pnor year, omil- 
led ueaunenls due to ■Tliecipisi i:iui\.iikihk-" Uccn^asL-d from l.7y''> to I Atn (p<,l)()l ), Worl^cd FTEs 
decreased from 38.05 in ZlMi m .13.42 in lirM quancr 2(K)2. Paid PTEs decreased from 43,76 to 37.59 in 
the same time periods. 

Tola] treatments 


Total tn^tmenLs 


'( Cotiversion 


Ave Tx /ptKlav 


« TrealmenLs BAN 


Ave pt^lavs 


Time saved per treatment (min) 


Ave nebs/pi-day 


Hours saved 


Total nebs ibed 


FTE (8 months 1 


(•osl.,le.iuhMisl> Neb 


FTE Annualized 




^f Conversion 


1,0 FTE RT 


Cost with vonverMOn 


tl,9 FTE Sav ings with AeroEclipse 


Cost withuul conversion 


Conversion cost diflerence 


Conversion cost difference 


Total Saiings 


Annuaiued increase 


CONCLUSION: Hospilal-wide conversion to BAN is cosl^iflective due to the decrease in administra- 
tion time. Therapist availability was enhanced, contnbuting to a significant reducuon in omitted treat- 

CLINICAL IMPLICATIONS: The conversion to BAN allows the ability to meet our patient care 
demands and for the reallocation of workforce needs in a manner that is clinically and economically 
advantageous. This may be one of several strategies to adda'ss the problems of Respiratory Care Staff 
shortages or high sea.sonal effect in the acute care facility. Quality is enhanced by decnsasing the incidence 
of omitted therapy. 
'CHEST 200 1, 120(4)2185 


Direct, Rapid Detection for Rifampin Susceptibility to M. 

'Jing Xu ' Gang Fu -Yangyi Hou -Dongxing Lv 

1 . Dept. of Respiratory Diseases, Tianjin Bailou Hospital, Tianjin 
300040. CHINA 2. Dept. of Pathology, Tianjin Hedong Hospital of 
Traditional Ctiinese Medicine, Tianjin 300160, CHINA 3. Dept. of 
Respiratory Diseases, Tianjin Heping Hospital of Traditional Chinese 
Medicine. Tianjin 300050, CHINA 

Objective: To evaluate the use of molecular biotechnology for direct, 
rapid detection of rifampicin-resistance mutations in M. tuberculosis. 
Methods 45 M. tuberculosis clinical isolates and 70 sputum samples 
were tested by polymerase chain reaction-single stranded conformation 
polymorphism (PCR-SSCP) technique. M. tuberculosis strain H37RV 
was used as control and compared with the result of susceptibility test. 
DNA sequencing was also performed in some of the strains. Results All 
tested susceptible isolates displayed identical SSCP patterns. Of 29 RFP 
resistance strains, 26 (90% ) had distinct mobility shifts that can be dis- 
criminated from susceptible isolates. 9 sputum samples that were 
successfully evaluated by PCR-SSCP showed concordant result 
acquired from BACTEC 460 method. As the result of DNA sequencing. 
it was observed that seven RFP-resislance phenotype of M. tuberculosis 
strains had missense mutation, in which 5 isolates displayed 
TCG^TTG or GAG mutations at codon 531,2 had CAC^TAC muta- 
tion at codon 526. On the other hand, one strain that was susceptible to 
rifampin exhibited identical nucleotide alignment to the sequence of 
rpoB gene. Conclusions PCR-SSCP could be used as a method for 
simple, rapid, and reliable detection of rifampicin-resistance mutations 
in clinical samples of M. tuberculosis. 


Changes of Eosinophil Cationic Protein and Soluble Interleukin-2 
Receptor in Bronchial Asthma 

' Yujing Wang -Jing Xu 

I. Dept. of Hospital Management, Tianjin Medical University, Tianjin 
300070. CHINA 2. Dept. of Respiratory Diseases, Tianjin Bailou Hos- 
pital, Tianjin 300040, CHINA 

Objective: In this study, an attempt was made to clarify theroles played 
by eosinophil cationoc protein (ECP) and soluble interleukin-2 receptor 
(sIL-2R) in the pathogenic mechanism of asthma. Methods: The fluo- 
rescent enzyme immunoassay (FEIA) and BA-ELISA were adopted to 
determine ECP and sIL-2R in sera from 30 healthy subjects. 61 patients 
with advanced bronchial asthma. ECP and sIL-2R in sera from 37 
patients were determined continuously after U'eatment. Results: The 
results showed that both the levels of ECP and sIL-2R in sera from the 
patients with bronchial asthma in the acute stage were significantly 
higher than those from the controls (P<0.0l ). Both the levels decreased 
significantly after treatment (P<0.01). Conclusion: ECP is an important 
infiammatory medium for airway inflammation, and the level of ECP in 
serum is conductive to the judgment for the activity and the severity Of 
asthmatic airway inflammation. The results indicated that a significant 
correlation exists between the activation of eosinophil and that of T-lym- 
phocyte. as well as between the increased level of ECP and the activa- 
tion of T-lymphocyte. 


Respiratory Care • September 2002 Vol 47 No 9 


Monday, October 7, 2:00-3:55 pm (Rooms 18-19) 















Enhancement De\ice for In-line Ventilator Aerosol Medication Delivery 

Bob Esletter RRT. Idichandi Idicula M.S. RKT . Anthony Dal Nogare MD 

Parkland Health & Hospital System, DaUa.s, 1 cxas 

Introduction: Deposition ol aerusoli/ed tnediculions from an in-line small volume nebulizer 
(SVN) has been shown lo be dependent on a number of factors including flowrate. nebulizer 
position in the circuit, and inspirjlon to c\pirjlor>' ratio (I:E) on a mechanical ventilator. In 
addition to these factop, constant tlou ) bi.Ls How i through the cin;uit also affects optimal deliv- 
ery*. We hypodiesized thai isolating inedicalion dcliverv faim ventilator cin;uit using an 
enhancement de\ ice (EDI can signitk .iniK impnne deliverv of aerosolized medication. 
Setup: Our enhancement de\ ice ct*nsisis ot .1 one wa> reservoir loop attached at the wye of the 
ventilalor ciauil using a female 10 ferii.ilc s 1 niiicctor This loop consists of a one way valve into 
the nebulizer T-piecc This is lolk^wcil by 1 5(1 ml corrugated tubing ( 1 -inch diameter) which 
acts as a reservoir This rescr\oiiconnecLs lo a patient T-piece connector with a one-way valve 
out in the connection 10 the other end ot tlie v.\c loop. 

Methods: We used a Michigan lung model w ith (wo filleis |H>sl(ioned 20Occ's (24inchesl from 
the \^ ye The lung compliance was set a( .^(Iciii H2() The riUHjel was \entllated sequentially 
with (WO volume vemiblors, TBirJ A\'S and Beat IIKKItes Bias Flow was set at lOL/M. Each 
ven(ila(or was set on A/C. RR L5, Vl .S(«l cc. FiO: 2\",. PEEP +i cmH20 at l;E latios 1 :3 and 
1:6 Location of the nebulizer pon on the inspltatory side of (he ventilalor circuit was varied 
between 50cc"s. lIXVc's, and I .S(Vcs pnor (o wye 'A( each locadon SV'Ns were adminislered 
wKh .^mls of .5mg/inl albuleiot a( 71JM foi I 5 niinu(es .ind samples were collccled SVNs were 
then adnanistercd through the nebulizer pon ot the enhancemeni de\ ice and samples u ere col- 
lected. The samples l filters with absorbed inedicalion 1 were removed from the circuit following 
each nehulization and dissolved in 8mls of 70r^r elhanol in a slenle container The fillers 
remained in ethanol for approximately 8 hours A sample of 0.7mls from each container was 
then analyzed using a spectrophotometer at 278 nanometers. The optical densities of each sam- 
ple were then plotted on a graph of known albuterol concentrations to convert the data to mg 
albuterol/ml. and results were compared. 








attached 50ml 

attached 100ml 

attached 150ml 

to the neb port in 

21 ■>. 500ml. 

prior to prov. 

prior to prov. 

prior to prox. 






Device 1 EDI 

1:E Ratio: 

Mean: 7S7 

Mean: 1 (W 

Mean: 1 IM 

Mean: I M: 


SD:(1 1^? 


SD: n :6n 

SD: 497 


Range: ssi-l III: 

Range: 887-1 161 

Range: 892-140.1 


40-12 LAI 





n lOmgyml 




Deposit: .^ y^ 

Deposit: 8 }"r 

Deposit: 9 6'r 

Deposit: le'r 

l:E Ratio: 



Mean: 0.776 



SD: 0S7 



SD:0 145 


Range: 11 -144- 6.1N 

Range 0443-865 

Range: 0667- 912 

Range: 1.1 76- 1-506 





Deposit: 0.:3mg/ml 




Deposit: .1 »>> 

Deposit: 4 8"r 

Deposit: 5 7Gi 

Deposit: i: ITt 

Discussion: Our data suggest thai ihe delivery' of nebulized medications can be significantly 
increased on any ventilator settings by attaching the in-line small volume nebulizer to the 
enhancemeni device. We belie\e that use of this device would enhance the care of 
mechanicaUy ventilated asthmatics, often requiring short inspiratory times and prolonged expi- 
ratory time. OF-02- 1 07 



Idichandi Idicula MS. RRT. Bob flstetter RRT. Anthony DaJ Nogare MD. 

Parkland Health & Hospital System, Dallas, Texas 

Introduction: Acmsolizcd bmnchodilatur has been administered conunuously using MiniHEART 
Continuous Nebuli7i:r to mechanically ventilated pauents who are sutTenng from bronchaspasm. 
To our knowledge, the ideal location to attach the nebulizer in the circuil to achieve the most deposi- 
tion uf aenisoli/ed particle m the lower airways is not currenlly idenlified We hyptrthesi/ed that 
attaching a MiniHEART ConUnuou-s Nebulizer between the humidifier outlet and the inspiratory por- 
uon of the venulaior circuit would significantly improve delivery of aerosolized nicUication 

Methods: A filter lo collecl the deposition of the aerosoUzed albuterol was connected lo the circuit 
wye with a 200 cc ( 24inches) corrugated tubing and a # 8 endotracheal tube. The filter was then 
attached to a Michigan Lung Model [compliance 35 cm H20) using a 100 cc corrugated tubing The 
model was ventilated sequenually with two volume ventilators, TBird AVS and Bear l(KX)tes Each 
ventilator was set on ,VC. RR 15. Vt 600 cc. Fi02 21 Vr. PEEP ^5 cm H20. IE ratio I 4, and the Bus 
Flow of 10 I7M The MiniHEART ConUnuous Nebulizer, filled with Albulernl Sulfate fi^r Inhalation 
0,5 ^•. was connected to the ventilator circuit pnor to the uy e Medication was nebulized coniinuous|\ 
at 2 LVM I as per manufacturer' s recommendation ) for 20 minutes and samples were collected The 
sample cttllection was repeated with the MiniHEART Nebulizer attached between the humidifier and 
the ventilator circuit- Samples (filters with absorbed medicauon) were removed from the circuit lol- 
lovvinj; each nebulizauon and placed in a stenle container with 8mls of 70 ^f ethanol The filter\ 
remained in ethanol for approximately 8 hours. A sample of 0.7mls from each container was then 
analyzed using a spectrophotometer at 278 nanometers. The opucal densities of each sample were 
then plotted on a graph of known albuterol concentrations to conven the data to mg albuteroL/ml and 
resulLs were compared 

Vent Settings 

\JC. f 15 B/M. 600ml. 

21%. PEEP 5, I:E 1:4 

Nebulizer attached 

at Ihe yy ye 

prior to proximal airyyay 

Nebulizer attaehed 
at the humidiner 
prior to the ventilator 

Bear lOOOtes 

Mean: 1 437 
SD: 14 
Range: 1 341-1601 
Deposition: 18 mg 
Deposition: I0 8<i 

Mean: 2 926 
SD: 002 
Range: 2 915-2 944 
Deposition: 4 16 mtr 
Deposition: 25 ''i 

Floyy: 64 UM 
Bias Floyy: 10 L/M 

FBird .4VS 

Mean: 1.253 
SD: 109 
Range: 1128-1.329 
Deposition: 1 568 mg 
Deposition: 10 7 <i 

Mean: 2.S*6 
SD: 0.027 
Range 2858-2933 
Deposition: 4 mg 
Deposition: 27 ''< 

Floyy: 63 L/M 
Bias Floyy: 10 UM 

Discussion: Our data suggest that the delivery of aerosolized medicauons using MiniHEART ConUn- 
uous Nebulizer can be significantly increased by attaching the Nebulizer to the humidifier outlet poor 
to the ventilator tubing connection. Further investigabons are needed to idenufv 
ways of improving the delivery of aerosobzed medication. QF-02-163 



Is this what happens to your expensive manometers? 

Are they missing, broken, out of calibration 
or sitting in a drawer somewhere when you need one? 


Respiratory Care • September 2002 Vol 47 No 9 

Monday, Octobhr 7, 2:00-3:55 pm (Rooms 1 8-19) 


James B. Fink. MS. RRT. FAARC . Alhena McCall; Aerogen. Inc. 
Mountain View, CA 

BACKGROUND: The liming of aerosol generation during a breath and 
particle size both impact drug delivery during controlled mechanical 
ventilation (CMV). METHODS: Five Aeroneb® Professional Nebuliz- 
ers were modified to generate aerosols ranging from 3.4 to 5.4 nm vol- 
ume median diameter ( VMD). as determined by laser diffraction 
(Spraytec^^'. Malvern). To determine the effect of this variable with a 
small dose of 0.5 iiiL. albuterol sulfate (0.5'7f solution) was aerosolized 
continuously and during a portion of inspiration (optimized phasic). 
The nebulizer was operated in the humidified inspiratory limb of a Puri- 
tan Bennett 760 Ventilator (tidal volume 500 niL. peak fiow 40 L/min. 
ramp fiow pattern, I:E ratio 1:3, rate 15/min) attached to an intubated 
adult lung model. The amount of drug deposited on an ab.solute filter 
distal to an 8 mm ID endotracheal tube was determined for each aerosol 
particle size and generation pattern (n=3). Drug was eluted from the fil- 
ter and determined by reverse phase HPLC with isocratic elution and 
UV detection at 275 nm. RESULTS: The percent of total dose ± stan- 
dard deviation (SDl delivered to the test lung for each VMD and 
aerosol generation pattern tested is shown below. 

SUMMARY: Optimized phasic aerosol generation yielded greater drug 
delivery for each particle size (p<0.0l, ANOVA). An inverse 

VMD (Jim) 












Optimized Phasic 






correlation (p<0.05, least squares analysis) was observed between depo- 
sition of drug and aerosol particle size across the range of particle sizes 
tested with both aerosol generation modes. CONCLUSION: A combi- 
nation of optimized phasic aerosol generation and smaller aerosol parti- 
cles resulted in the most efficient drug delivery in vitro when using the 
modified Aeroneb Pro during CMV. 


WITH COPD. S Kesien ' . S Menjoge ' . PCornelissen -. 'Boehringer 
Ingelheim, Ridgefield, CT, USA and -Alkmaar, NL. 

COPD is characterized by incomplete spirometric reversibility to 

pharmacologic intervention. Patients are often characterized as 
reversible (R) or irreversible (IR) on the basis of a single test day. We 
hypothesized that such characterization does not adequately profile a 
patient's ability to respond on subsequent test days. We therefore 
sought to determine the reproducibility of reversibility to ipratropium 
(as defined by a >l5'7r increase in FEV| within 3 hours) and whether an 
"irreversible" patient could show reversibility on another test day. A 
retrospective analysis was conducted of patients who completed all test 
days in a one-year COPD clinical trial where serial spiroinetry was per- 
formed before and after ipratropium 40 meg (0.5, I, 2, 3 hours) on 7 
occasions. Mean (SE) FEV| =1.22 (0.03)L. mean (SE) age = 64 (0.8) 
years. Proportion {Vc) of patients showing reversibility on a given test 
day is noted in the table according to whether reversibility was achieved 
on day I (Rday I vs. IR day 1). 

Study Day 
















Rdav 1 (n=9l) 








IRday 1 (n=23) 







Of 7 test days, only 0.99c were always IR and 33"* were always R. 
Approximately 83% of patients demonstrated R on at least 4/7 test days. 
In conclusion, reversibility to ipratropium 40 meg is frequent and a 
response of less than 1 5^^ on a given test day does not preclude a 
response on a subsequent test day. 

This work is supported by Boehringer Ingelheim 


















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Respiratory Care • September 2002 Vol 47 No 9 


MONDAY, October 7, 2:00-3:55 PM (Rooms 20-21) 


Chuck Terhune . Hemg Lee Tan. SiudenLs, Respiralory Therapy Program Indiana Univer- 
sity. Jeffery A. Atiwcxxl. RRT. E4uipment Specialist. Respiralory Care. Clarian Health, 
Linda Van Scoder. EdD, RRT, Respiralory Therapy Program. Schools of Allied Health 
Sciences and .Medicine. Indiana UniveiMiy. BACKGROLIND The use of manual re.sus- 
citation bags in neonates requires an inline manometer to measure the peak inspiratory 
pressure (PIPl delivered to them in order to prevent excessive pressure resulting in baro- 
traumas and over-distension. PURPOSE This study was earned out to determine the 
accuracy of disposable manometers. METHODS This descnptive study included a con- 
venience sample of thirty disposable manometer, manufactured by three companies- 
Sims/Ponex. EMS and Mercury. Ten manometers of each brand viere tested at 20 
cmH;0 and }0 cmH;0. A mechanical dev ice w as designed to deliver consistent flow, 
rate and pressure throughout the testing. Ten readings for each of the thirty manometers, 
were ttcorded at each pressure. The disposable manometer readings were compared to 
simultaneous pre.ssure readings registered on a RT 2t)0 calibration analyzer made by 
Timeter. The meiui pressure, standard deviation and range for each brand were 
delemiined using Microsoft Excel descriptive statistics. RESULTS At 20cmH:O. EMS 
had the smallest mean. 21.42 cmH;0 and the smallest percent error. 7. 1 29c. among the .1 
brands of manometers. At 20 cmH;0. Mercury had the largest mean. 22.72 cmH;0 and 
the largest percent error. LI. 6.^9; . At 30 cmH;0. Mercury had the smallest mean, i 1 .6.^ 
cmH;0 and smallest percent error. 5.44'?r. At 30 cmH:0. Sims/Portex had the largest 
mean. 33.(McmH;0 and the largest percent error. lOLS^f-. CONCLUSION All 3 brands 
consistently underestimate the true PIP reading at 20 cmH;0 and 30 cmH:0, At 20 
cmH;0. EMS had the smallest percent error, standard deviation and range, hence it was 
the most accurate, reliable and consistent. At .30 cmHnO. Merc-ury had the smallest per- 
cent error, however. EMS had the smallest standard deviation and range, hence EMS was 
die most reliable and consistent but Mercury was the most accurate. 


30 cmHjO 1 














Standard Error 







Percent Error/"f 





















StandanJ Deviation 






























Cindy Peters . Prayoun Poulima. Respiralory Therapy Students. Indiana Univer- 
sity, Deb Pearson, RRT, lU/Riley Respiratory Care, Clarian Health, Linda Van 
Scoder, EdD, RRT, Respiratory Therapy Program, School of Allied Health Sci- 
ences and Medicine, Indiana University. 

BACKGROUND Oxygen is used in patients to maintain sufficient oxygena- 
tion to the tissues and to avoid hypoxemia. Therefore, il is essential to verify 
that the flowmeter is delivering the proper amount of flow to the patient. A 
review of the literature found limited data exists on Thorpe tube oxygen 
flowmeters. The review of the literature rev ealed no current information on 
oxygen flowmeters. Most information found regarded anesthesia vaporizing 
flowmeters. That reseaa'h discovered inaccuracy ranges from 10-40%. The Um- 
ited amount of data found on oxygen flow meters indicated that they also tend to 
be inaccurate. PURPOSE This study was conducted to find out how accurate 
oxygen flowmeters in clinical use are and whether they meet the Compressed 
Gas Association requirements. METHODS This study included a 
convenience sample from tfiree hospitals. At two of the three hospitals. 20 
flowmeters were randomly chosen from different areas in the hospital. At the 
third hospital only 10 flowmeters were tested. The randomly selected 
flowmeters were then tested at different flows- 2L'min, lOL/min, I5/min and a 
"flush" setting. The apparatus used to test the flowmeters was an RT-200 
(Timeter) analyzer. Each flowmeter was tested twice to ensure accuracy of the 
reading. Four dift'erent brands of flowmeters were tested; Precision Medical. 
Timeter. Puritan, and Chemtron. RESULTS We found that most of the 
flowmeters tested fell witfiin the requirements set by the Compressed Gas Asso- 
ciation (CGA). The CGA range for accuracy at 2 L/min is 1 .8-2.2 L/min. The 
mean flow s of hospitals 1 . 2 and 3. were 1 .69 L/min, 2.09 L/min, and 2. 1 L/min 
respectively at a set liter flow of 2. The CGA range for accuracy at 1 L/min is 
9.0-10.9 LVmin. The mean flows for hospitals 1.2and3were 10.27 L/min. 
10.72 L/min. and 9.75 L/inin respectively. The CGA range for accuracy at 15 
L/min is 13.5-16.5 L/min. The mean flows for the hospitals were I4.35L/iTiin. 
14.16 L/min. and 15.9L7min respectively. Flush settings on the flowmeters had a 
wide range of mean flow. At hospital 1 the mean flow was 79.67 L/min. At 
Hospital 2 the mean was 89.37 L/min and at hospital 3 the mean was 
56.0917min. CONCLUSION Although the majority of the flowmeters tested 
fell within the requirements only a small sample was taken. A more extensive 
research study should be conducted to test accuracy. Research should be not 
only by flows but by brands as well. It can be concluded that flowmeters 
provide a wide variety of flush flows. OF-02-027 



Nicole Giudici. Youngstown State University, Youngstown Ohio. Teresa A. Volsko. BS. 

RRT. FAARC, University Hospital Health System Cleveland, Ohio 

Background: Clinicians commonly believe that Fio changes on an air-entrainment 
mask are accomplished similarly to those of a simple mask or nasal cannula, adjusting 
only the flow on the flow meter. However, with an air-entrainment mask, changes in 
delivered Fio, are two-pronged — adjusting the entrainmenl port on the mask and setting 
the manufacturer's recommended flow rate. The purpose of this study was to evaluate the 
effect flow manipulation alone had on Fio^ delivered by an air-entrainment mask. We 
hypothesized that changes in flow only would not significanUy change delivered Fio^. 
METHODS; A face was simulated using a clay model. A Mini Ox III* oxygen analyzer 
was calibrated and placed on the model where' the nose is anatomically located 
(unoccluded). An air-enttainment mask (Hudson RCL*) was then applied firmly to the 
clay, assuring no leaks. The enlrainment pon was adjusted to deliver the desired Fio, set- 
tings ( 24. 26. 26. 28. 30. 35. 40. and 507f ). The Fio, was analyzed and recorded after a 
Iw o-minute stabilization time for the recommended flow. Flow was set at - 1 . -2. -f 1 . and 
+2 L/min (relative to the manufacturer's recommended flow) for each Fk>, setting. Fio, 
was analyzed at each flow vanation at each F|o, setting after a two-minute stabilization 
time. The experimental conditions were repeated tfuee times. Change in Fio, was calcu- 
lated as desired Fio, - measured Fio,. Dala were analyzed using two-way repeated mea- 
sures ANOVA. Si^ificance was established at/i < 0.05. RESULTS: As flow increased 
or decrea.sed. there was a concomitant statistically significant change in Fio, across the 
range of desired Fjo, settings, p < 0.001 , The greatest change in F|o, ( 1 .5% )"is seen with 
the 30% and 35% settings. Mean values (± SD) for the combination of Fio, settings 
across all flow variations are represented as summary data in the graph below; 

J 10* 
m 00% 
I 1 0% 

1 1 1 M 

CONCLUSION: Although statistically relevant, the changes made in flow for each 
desipjd Flo, were witiiin the error specifications of the analyzer (± 2% ) and would not be 
clinically significant. F|o, cannot be reliably adjusted by changing tiie flow on an enlrain- 
ment mask. " OF-02-034 


Nicole Giudici. SRT*. Teresa A. Volsko RRT. FAARC* 

Youngstown State University. Youngstown, Ohio,* University Hospitals Health System, 
Case Western Reserve University Cleveland, Ohio* 

Backgroimd: Pressure manometers monitor airway pressures in all patient types during 
manual ventilation to assure ventilating pressures are adequate, but not excessive enough 
to conuibute to barotiauma (J Trauma, 1996;40:320 - 322). We evaluated the Disposable 
Manometer (Mercury Medical*". Clearwater Rorida) in a laboratory setting to determine 
the accuracy and values for unlabeled reference markings on the manometer's face. This 
manometer is a small, 1- 1/2 bv 2 inches, iighiw eight spring-loaded de\ ice that can mea- 
sure pressures between 5 and 60 cmH;0. The manometer's face contains labeled refer- 
ence values of 5. 10. 15. 20. 30. 40. and 60 cmH:0. as well as unlabeled reference mark- 
ings, represented by a dot which fall betv\ een each of the first five reference values. We 
hypothesize Uiat the manometer design w ould prevent consistent accurate measurements 
during manual ventilation. We also sought to determme the approximate \ alue of the 
unlabeled markings on die face of the manometer. Methods: The Biealh Tracker 1 705 
(Core-M Precision lnslTuments^ West Newton. M.A) was used to perform 
measurements. It was zero calibrated then calibrated at 5. 10. 1 5. 20. 30. and 40 cmHiO 
wiUi a U-tube manometer. The Breath Tracker was connected to the disposable manome- 
ter w itii small -bore connector tubing, a slop-cock, and a 60 mL piston syringe. .Air from 
the syringe was injected until the pressure indicator (dial) on the manometer reached the 
center of the reference number and/or dot. The value displayed on the Breath Tracker 
was recorded, in cm H:0, for each of die numbered reference values and dots from 5 
tiirough 40 cmH:0. Ten manometers were tested and this procedure was repeated 3 
times for each manometer. Mean (± SD) x alues and percent max error per reading were 
calculated tor each marked reference value. Delertnination of the unlabeled reference 
markings was accomplished by calculaung die mean of all die measured values dotal of 
30 measurements) for each of die unmarked reference dots on the 10 devices tested. 
Results: Percent max error per reading and mean value of all readings is displaced in the 
table and graph below respectively. The calculated value of each unlabeled reference dot 
is displayed in the table below followed by a (*). 

Reference Value 

Max Error ( % of reading ) 















8 « 15 3B 

Conclusion: The manometers displayed a small 
constant systematic error, with mean values 
falling close lo the line of identity. The large max 
error may be attributed to the difficulty determin- 
ing the target pressure relati\ e to the true reading. 
This may pose a problem when attempting to 
monitor airway pressures during manual ventila- 
tion in the neonatal population. n9 114 



Monday, October 7, 2:00-3:55 pm (Rooms 20-21) 


Muneyasu Sha. MP : Tetsuya Miyaji, RT; Yuki Hiasa. MD; Nobunori 
Kobayasi, MD; Akito Ohmura. MD;University Hospital Mi/.oiiokuli, 
Teikyo University, Kawasaki, Japan. 

Introductiim: Pulse oximetry has become a key element of 
polysomnographic recording. However, motion arlifaci is a common 
cause of oximeter failure and loss of accuracy. The purpose of this study 
is to evaluate effects of motion on two newer pulse oximeters and 
compare pulse oximeter data with co-oximeter values (Sa02). Methods: 
Seven healthy volunteers whose average age was .18 years were 
monitored by 2 different types of pulse oximeters; Nellcor N-.'?y.') and 
Masimo SET. Sensors were placed on digit 2 and 4 of the hand and foot. 
The Opposite hand was used to insert an arterial cannula. Hypoxia was 
induced by decreasing the fraction of inspired oxygen to change Sp02 
values from 100 '7r to 68 '7c. We measured the time from hypoxia onset 
until onset of the Sp02 dip (on-lag) and time until lowest Sp02 during 
nonmoving periods and then hand and foot motions of tapping or rubbing 
for I minute were studied. Sp02 and pulse rate from each oximeters were 
recorded digitally throughout the experiment. Artifact during motion was 
defined as the increase or decrease in Sp02 of 4% or greater than Sa02. 
Results: The on-lag times were 37 s and 43 s and the times until lowest 
Sp02 were 143 s and 157 s for the Masimo and Nellcor oximeters 
respectively. The incidence of artifact was 26 9r of the Masimo placed in 
hand. 32 <7r of the Masimo in foot. 38 Vc of the Nellcor in hand and 47 % 
of the Nellcor in foot. Conclusions: The lowest Sp02 values for both 
pulse oximeters during hypoxic challenge were not significantly affected 
by motion. The results were in disagreement with the previous reports. 
Our study demonstrated that Masimo SET significantly reduced the num- 
ber of motion related artifact; This result shows that the Masimo SET 
may improve the reliability of desaturation detection in sleep apnea 
patients. References: Brouillette RT. Lavergne J. Leimanis A: 
Differences in pulse oximetry technology can affect detection of sleep- 
disordered breathing in children. Anesth Analg 2002; 94: S47-S53. 


SPIROMETER While K RI'FT. Kurokaw;i N KRT and McOinliy K RCPl ['ulmonary 
tuiKiioii I .i|-H>nUor>. Cleveland Clinic I-oundallon. <>.'>(X) HufUd Ave.. Cleveland. OH 44iy.S 
Background: We underttiok tiiis study to eompare llie aeeuniey »l Ihc portable Jaeger 
Spin:)Pn)T*'' differenlial pressure tntnsduccr/pneuniolaeh spirometer with our larger latioralory- 
basetl spiromelcrs, 

MethutLs: We otilained a lolal of twenly -scLs ol spin)nielr>' sessions (ninjiinum .^ 
cltorts/scssion 1 on both liie Jaeger SptroPm' " and the Jaeger MiLsierscrcen PFT/Body '"(both 
inslminents faini Viasys HealliiLare. Yorha Linda. CA ) fnim six nonnal subjects experienced in 
pertbrming spirumetiy tests (Hve female, one male, ages: At) lo 56) The sequence of 
msinimenrs u.sed in each session was varied randomly. Repeal sessions were obtained on differ- 
ent days and the instrument order was again varied in a random fashion Comparisons of the 
standard spintmclry indexes forced vital capacity iFVO. fon.ed expiralory volume in one sec- 
ond (h"EV|), peak expiratory flow rate(P[:t-")iind midK;xpiralory How nitelFtihis 7SMwere 
made. The largest [-"VC and ITiVi from each mslrument-session were compared. The PEF and 
niFis-75'i fmm the insuiimcnt-session effort that had the of F"VC and FT.V , were 
compared- subjects and those administering tlie lest were not blinded iis lo which 
inslruinenl was being used. 

Results: Seventeen of twenty (8,')%) of the largest FVCs and all (1(X)%) of the largest FEV|S 
fmm each instnimenl al each session agreed within 0,21 . Tlic mean results and differences 
i±SD) for the 20 scis o! [llc.isiirvTiicnts arc shown in tile lollowiiip table Sludcnl's l-lesi was 
used when Ihcre was nonnal dislribulionol Ihedat.i, nllicrwisc Ibe NtannWhimev rank sum 
lest was used to delect slalislically significant diltere-nces. 





P value 




11 III 
llO 141 

iMann WhiUiev Rank Sum) 

FEVi (L) 

2 94 



(Mann-Whilney Rank Sum) 






(Mann- Whitney l^ank Suml 







Experience: The SpiroPro unit is a ver> portable spirometer that uses disposable flow sen.sor* 
The system can download results to our main PFT dalaba,sc. The user interface is moderately 
easy to use, Dunng te.sting, the unit displays a llow-vnlume curve hut it is difficult lodeiennine 
when the patient has achieved end-of-test cnlcria. the most common problem in spirometry 
testing. We recommend a digital display of flow ( niL per second ) be added to aid in determin- 
ing when to end the collection. 

Conclusions: No statistically or clinically significant difference was found for any parameter 
we evaluated. This study demonstrated acceptable agreement between the portable hand-held 
SpiroPro^"' spirometer and the larger MaMerScreen PFT/Body unit, suggesting that results 
from these units can be used interchangeably. However, the evaluations were 
conducted on normal subjects, further evaluation with subjects having low volumes and flows 
is warranted. OF-02-038 


Steve Siitig RRT . Steven Sobzak MIS, CSP. CIH. 
Jeff Nesbitt BS, ASP. Joel Mashek RRT 
Mayo Clinic. Rochester. Minnesota 

Purpose: Since there are few commercially designed and developed hearing 

protection systems for this environment and small patient population, we set up 

a study to look at the noise level exposure levels to newborns and infants found 

in three medically configured aircraft during flight. 

Equipment: 3 Quest (Type II) Noise Dosimeters Model Q-300. One hand held 

GEL- 266 OBS (Type I) Noise Level Meter 

Methods: Three Type II Dosimeters were used in each flight. One dosimeter 

was inside the isolette and the other two on research team members measuring 

noise level exposure in various points in the aircraft cabin. The CEL-266 hand 

held noise meter was utilized to measure real time levels in various points of the 

aircraft cabin and isolette during the flights. 

Results: Sound levels were time weighted over the entire flight duration in 


Noise Level Isolette Noise Level Crew 
BK-117 83 90 

King Air B 200 78 84 

Pilatus P 12 80 86 

Conclusions: Even though flight times may be considered short exposure, 
cumulative exposure is still a factor in progressive hearing loss. There is very 
little literature concerning high-level noise exposure in neonates and young 
infants. There are numerous studies looking at ICU noise level exposure. 

The measured noise levels were higher than the research team had 
envisioned. There was no significant increase in isolette noise levels with the 
door or portholes open as in doing cares/assessment in the fixed wing aircraft 
but a 2 dB increase was noted in the helicopter. During our testing, we 
attempted several engineering methods attempting to decrease the environmen- 
tal noise levels without success. Exposure at such a young age cannot be harm- 
less and needs to be addressed in this population. Recent list-serve postings 
show some flight programs attempt to modify commercially adult designed 
hearing protection devices or do nothing at all. Our research continues and we 
are now looking at including a.ssessment of vibration levels and studying other 
medically configured aircraft and potential solutions. nF-02-074 

Brian Tiep. MD . Mary Bamett. RN. Pulmonary Care Continuum. Western University 
Health Sciences. Pomona CA. 

Background : The Non-rebreather mask has been the standard for delivering high flow oxy- 
gen. Unfortunately, difficulty in maintaining a facial seal often leads to a lower than 
expected FIO:. Some patients find the mask uncomfortable and are unable to eat or com- 
municate while wearing it. Nasal oxygen is not typically regarded to be a high flow option, 
because of lack of efficacy, mucosal drying and discomfort. Recently, a high flow, warmed 
and humidified, nasal O: delivery system (Vapoihemil was introduced that comfortably 
delivers nasal 0:> up to 40 L/m. The present study was designed to measure FIO: attainable 
by mask and nasal cannula and to trace the delivery flow through the upper airways. Meth- 
ods : We constructed an upper airway model to trace flow of ultrasonic fog and measure 
gas exchange at the modefs trachea. A mouthpiece 'T" junction at the trachea allowed the 
subject to breathe into the model using the model's upper airway architecture and dynam- 
ics. We measured O^. CO; and respiratory flow in a normal subiect breathing in a consis- 
tent and controlled flow pattem at a rale of 2f) breaths/min u ith the model wearing the 
mask (M) VS nasal (N) cannula. O^ was delivered at 10. 15. 20. and ,^0 L/m through each 
device. Results : Peak FIO: ^ measured at the beginning of inspiration via nasal cannula 
and mask: lOLVm : N=62'7r M=487r; 15 L/m : N=82^/r M=65'/,; 20 Unv . N=90% M=7I 7r: 
30 L/m : N=95% M=93%. End-exhalation FEO: via nasal cannula and mask: IQ L/m : 
N=38'7, M=37?r: 15 Um : N=52'7. M=S27f ; 20 L/m : N=54';f M=509^; 30 L/m : N=729'f 
M=7 1 %. Ultrasonic flow studies recorded on digital video demonstrated that mask Ot 
remains outside the nose and mouth until the subject inhales; whereas nasal O; is stored in 
the upper airways dunng exhalation for additional delivery upon inhalation, Conclusipn-s: 
High flow nasal cannula delivery is more efficacious than the non-rebreather mask al 
equivalent flows, due to O: storage in the upper airways during exhalation poised for deli\ - 
ery upon the next inhalation in addition to the continuous suppK flow. High flow nasal O; 
can be an effective option for patients with high flow requirements. Clinical studies are 
recommended to evaluate the impact of high flow, wanned and humidified O; following 
extubatitin. during sleep, and in the management of exacerbations 

no, («}vt«NaMlCMnul«V« Mash 

30 um 

30 L/m 





ftO , 









N M ' N 

M ' N M ■ N M ■ [ 


Respiratory Care • September 2002 Vol 47 No 9 


Monday. October 7, 2:00-3:55 pm (Rooms 20-21) 


Susan R. Ogrinc. RRT . James E. Martin. RRT, DepanmenLs of Pulmonary Services, and 
Pediatrics. MetroHealth Medical Center, Cleveland, OH 

BACKGROLIND; Posiii\e Airway PiBssure (PAP) devices are used for secretion 
mobili/ation, and prevention and treatment of alelecta-sis. The E?.PAP™ Positive 
Airway Pressure Therapy System provides positive pressure during the total respiratory 
cycle. Administering 5-15 L/m of compre'ssed gas into tfie g;Ls inlet pt)rt is amplified 
fourfold by the coanda effect, which produces the desired therapeutic pressure level. The 
purpose of Uiis study was to see if ptisitive pres.sure was maintained throughout the respi- 
ratory cycle during simulated spontaneous breathing. METHOD: A two-section test 
lung ( 26001; Michigan In.struments) was used to simulate spontaneous breailiing. A 
Puntan Bennett 7200 \ entilator in volume mixle powered the driving chamber. The 
EzPAP was attached to the distal pori of the test chamber. A coupler was attached 
between the two compartments of the lest lung. Peak Inspiratory Row Rates (PIER) of 
10, 15, 20, 25, 30, -40, and 60L7m were achieved by varying the ventilator tidal volume 
and peak flow rates. The resistance ( RP5 ) on the test chamber remained constant. An 
airway monitoring device ( Bicore CP I IX) i was placed between the EzPAP and test 
chamber and used to set spontaneous PIFT^ and measure pressures. An anoid manometer 
was attached to the pressure port of the EzPAP, Dunng simulated spontaneous breathing, 
the lowest inspiratory pressures were recorded using 5,10 and 1 5 L\m of Oxygen. Two 
additional devices were randomly checked at various PIER to ensure reproducibility of 
re-sulLs (+1 cm H;0). RESULTS: The lowest inspiratory pressure levels are recorded in 
the Chan below. PIFR from 0-30 L\m maintained positive pressures for all three-oxygen 
settings. At 40 L\m the 5 L\m o.xygen setting resulted in an ambient pressure reading. 
Only l5L\m o.\ygen maintained a positive pressure during inspiration at all flowrates 



s. « 

1 to 




-»-5 L*nC2 

■"•*-—»_ *"" — *^ 


— * — -~~^ ^ 

a 1SLVn03 

*~~"* — ♦— -*_ \. 


10 IS ID 2S w 40 eo 

CONCLUSION: EzPAP provides positive pressure throughout the respiratory cycle 
except for extreme inspirator)' flow rales inakmi: ii a suitable PAP adjunct. Use of a 
pressure manometer and the continual reinlnrccnicnt of correct breathing can ensure the 
desired pressures. OF-02-085 


Mark J. Heulitl MD, Patricia C. Wankum MD. Stacy M. McBain , 
Shirley J. Holt RRT, Tracy L. Thurman and Katherine L. Menees '. Pedi- 
atrics, UAMS/Arkatisas Children's Hospital. Little Rock, AR. 
Background: Weaning mechanical ventilation in patients optimally 
includes meeting their needs by making frequent ventilator adjustments. 
Coniputeri/ed closed loop ventilation (CLV) is designed so the ventilator 
can be interactive with the patient's needs by making breath by breath 
adjustments in both control and support modes. Objective: The 
objective was to document the level of work of breathing (WOB) and to 
validate that a CLV ventilator algorithm responded aptly using a neona- 
tal animal model with drug induced apnea. Methods: We ventilated six 
sedated piglets using CLV in PRVCA'S. PC/PSV.VC/ VS. Data were 
collected using both a computerized respiratory monitor and data acqui- 
sition system. Data collection began with the animals breathing 
spontaneously in each support mode followed by the administration of a 
short acting neuro-muscular blocker to mduce apnea, thus allowing the 
ventilator to switch between modes automatically. Data were collected 
before, during, and after apnea to observe the duration of inspiratory 
effort, trigger response time, and any significant pressure or flow 
variances of the CLV feature. In addition, patient WOB (WOBp) was 
measured before and after each phase. Results: We found no instances 
of CLV failure to follow the predetermined algorithms. There was a dif- 
ference in duration of inspiratory effort by each animal during triggering 
in the post-paralysis phase for PC/PS (p<0.05). Maximum flow reached 
was lower in the post-paralysis phase for PC/PS (p<0.05). We also found 
WOBp decreased in the post-paralysis phase for all modes tested 
(p<0.05). Conclusions: We conclude that differences in response time 
and maximum flow reached were due to continued weakness from the 
neuromuscular blocker. Disclosure: Unrestricted grant from Siemens 

^^^'^'^l OF-02-088 


Theron Van Hooser M Ed RRT . Ed Madsen. Tom Flood, Research and Dcvelopmenl 
Depanmeni. Ballard Medical Product.s. Draper Ulah Background: One advantage of using a 
closed suclion calheier system for suction is that the patienl does nul need to he disconnected 
from the venlilaior breathing circuit (VBC). All closed suction systems should be rinsed follow- 
ing the suclion procedure. Dunng the nnse procedure, some ventilator tidal volume is lost 
(removed), because the catheter lip is still within the VBC, Funhemiore. accidental aclivation of 
suclion may occur because of patient position or inad\cnent manipulation. In orderio alleviate 
this situation, a new design was chosen I Ballard TRACH CARE-72*. REF 227) with a separate 
and integrated cleaning chamber. When ihe catheter is fully withdrawn, a flapper valve cXoses, 
over the catheter, within the cleaning chamber. This valve restricts the amount of volume 
removed from the VBC and causes saline to be drawn from the attached vial. This effectively 
limits the amount of volume removed from the VBC. and makes ihe rinse procedure essentially 
"one handed". The aim of this study was lo measure, dtxumenl. and compare the amount of lidal 
volume loss during rinse or accidental thumb valve activation. Methods: 26 samples each of the 
onginal design REF 22 1 0. and the new design REF 227 were selected at random. A Nellcor. 
Puritan-Bennett 84() adult mechanical ventilator (Mallmckrodi Inc. Carlsbad CA) in volume con- 
trol mode was set as follows; tidal volume 800 ml, rate 20 bpm, PEEP ?> cm/H20 trigger sensitiv- 
ity -20 cm/ H20, Negative 20 trigger sensitivity was chosen to avoid auto trigger of the ventilator 
The VBC was attached to a calibrated Michigan Test Lung (Michigan Instruments, Grand Rapids 
Mi,), with the resistance and compliance set for a "noniial" adult. The samples were placed into 
the circuit in the normal configuration The samples were attached lo an electrically powered, 
vacuum source (Mobile Vac HI. Aeros Insi, Guniee III) set al -120mm/Hg- Each sample was 
connected in ihe nonnal fashion. The thumb valve w,is depressed for 30 sec to simulate acciden- 
tal aclivation. The catheters were nnsed wilh \5 ml of saline (Ballard REF 1 16). Mean tidal vol- 
umes delivered into the test lung through ihe VBC were recorded, before suction, after suction, 
before nnsing and after nnsing. Results: Pre-suction and prc-nnse prtxedutes both systems 
delivered Ihe same tidal volumes. There was essentially no diflcrcnce between ihe REF 2210 
design and REF 227 design. After suetion, there was a large difference of 527. 5-mI, and 627.9 ml 
after nnsc- The REF 2210 design essentially removed all tidal volume during ihe rinse 
priKX-durcs, Discussion: Because the tidal volume is drawn into the catheter ralher than delivered 
to the VBC. ii is considered "lost". It should be noted thai this is not a realistic clinical situation 
and that actual tidal volume loss during simulated suclion was not measured. 1 2 seconds is the 
recommended maximum time suction should be applied during the actual suclion event. We used 
30 seconds which was excessive and aggressive for normal clinical airway suclion. hui probably 
common for accidental aclivation. It should also be noted that since Ihc ventilator was set on vol- 
ume control and negative 20 sensitivity, the \cntilator did not trigger did not deliver additional 
flow. Wilh the venlilaior set to deliver only 8(H) ml. ihe REE 227 delivered 527.5ml and 627.9ml, 
REF 2210 delivered none, a clear and dramatic difference, With REF 227, .some volume was lost, 
but overhalf of the desired 800 was delivered into the test lung during the rinse procedure. This 
test was designed to document ihe difference in performance of the iwo designs, and is noi repre- 
sentative of an actual clinical situation. Conclusion: The new design. REF 227 (TRACH CARE- 
72' ) dramatically reduces ventilator volume loss as compared to the original REF 22 1 design 
during the rinse event or during accidental thumb valve aclivation. OF-02-094 


Theron Van Hooser M Ed. RRT . Tom Flood. Chns Blaes. Beveriy Hyle, Ed Madsen Reseanrh and 
Development Department, Ballard Medical ProducLs, Draper Utah. 

Background: Recent studies have shown reduced rales of venlilaior a,v»ociaied pneumonia (VAP) 
by maintaining a closed circuit beyond 24 hours. A previous study has shown that in ihosc hospitals 
surveyed, the majority of paiienls are mechanically ventilated for 72 hour> or les.s, Ballard TRACH 
CARE* 72. REF 227 (Kimberly-CIark Corp,. Draper. Utah) closed suction system was designed 
for 72 hour use. The aim of this study was to compare the ability of REF 227 lo clean the calheter 
tip as compared widi die 24 hour Ballard TRACH CARE*, REF 22 10, Methods and materials: 
Two hundred and forty calheiers were equally divided (1 20 REF 2210 and 120REF227). ihen 
challenged wilh four common bactenal pathogens. Non-viruleni strains of these four bactena were 
chosen tKcause ihey repre.seni common respiratory pathogens which are responsible for 
approximately 41% of nosocomial pneumonias in the United States. 

Staphylococcus aureus ATCC #6538 
Klebsiella pneumonia ATCC #23357 

Pseudomonas aeruginosa ATCC #27853 
Escherichia coli ATCC #8739 

The calheleni were- challenged by simulating the suction procedure over 24 to 72 houT^. A 
simulaied mucus solution was prepared in four containers Each container of simulated mucus was 
inoculated with one species of organism al I x 10'±0.5 loglO CFU/ml. This level simulates the 
level of coloni/Jtion m the respiratory secretions of a patient with pneumonia, The inoculum was 
stored at room temperature and new inoculum wa^ prepared every 24 hours. An AEROS Mobl-Vac 
III vacuum system and a saline vial were attached to each cadieier. The vacuum level was set to 1 20 
±5 mm Hg 115 9 ± .6kPal Each catheter was dipped into the inoculum appmximately ScenUme- 
ten.. Inoculum wa.s suctioned approximately 30 centimeters up the in.side of the catheter. The 
calheier w;ls then removed from the inoculum. The catheter lip was cleaned, by a[^lying suction 
and retracting the catheter, as per the instructions for use. The REF 22 10 catheters were cleaned 
with saline by the usual method of squeezing the saline vial. The REF 227 calheier design has a self 
closing valve or "flapper", which closes under vacuum which causes the vial to empty into the 
catheter-cleaning chamber. Twelve suclion simulabons were performed every 24 hours, using the 
following schedule on each day: 12:00. 13:00. 15:00. 16:00. I8:(X). 19:00, 21:00. 22:00. 06:(X). 
07:00. 09:00. and 10:00. Al 1 2:00 following the last suction simulaiion. the catheter was extended 
and the first 2 centmieletN of the lip was xseptically removed. The bioburden was measured al 24 
and 72 hour time point-s, Catheters were tested in groups of five replicates per catheter. Bacteria 
grow at an cxptineniial rale. To improve accuracy, the data was converted inlo Log (CPU) before 
Ihe analysis was pcrfomied. TTiis is consislenl with USP guidelines for antimicrobial effcctivcne,ss 
testing Statistical analysis was performed using SAS statistical software. Results: REF 2210 had 
:7S,()(HK-fa i/ml at the end of 24 hour-;, and REF 227 had 19.800 CRI/nil at the end of 72 hours. 
Ihis reprcscnls all log reduction in tip colonization. REF 227 has an overall significant (p < 
0.00 1 ) reduction in colonization as measured by tip colonization. Conclusions: The design has a 
significant effect on catheter tip haclcnal coIoni7,alion of closed suction systems, 



Respiratory Care • September 2002 Vol 47 No 9 

Monday, October 7. 2:00-3:55 pm (Rooms 20-21 ) 


Jim Kcbcl RRT . Mike Trcvino RK T. c;.tr\ L Wciiisicin Ml). ?-VCP. Prcshyicrian 
Hospital of Dallas, Dallas. Texas 

Background: The Respiratory Care department performed 1.1 1? spirometry stud- 
ies between January and December 2(K) I . Of these. 147 were performed at the 
patient's bedside. The department uses the Punlan Bennett Renaissance (PB KM}) 
spiromclr> s>stL-m The remainder of all studies was perfoniied m the Pulmonary 
Lab. Bedsulc spirometry is one of the least performed procedures that therapists, in 
our facilil) . are required to perform The purpose of this study was to evaluate the 
quality of bcd-side spirometry performed. 

Methods: A retrospective review identified that thirty-eight different therapists 
performed bedside spirometry. Sixty-three patients were screened for spirometry 
only, and an additional eighty-six patients had pre-and-post spirometry performed. 
Acceptability and reproducibility were assessed against the revised AARC Clinical 
Practice Guidelines lor Spirometry that is largely based on American Thoracic 
Society (ATS) standards 

The tests were further evaluated to identify the root cause of failure. These cover 
two broad categories, therapist error and patient effort. Therapist error was defined 
as the acceptance of a failed test with minimal trials. Patient effort or ability was 
defined as a poor effort stated on the report by the administering therapists or the 
inability to perform a reproducible effort. 



Passes AARC CPG 

Failed AARC CPG 

Pre & Post BD (n=86) 

10.5% (9) 

89.5% (77) 

Pre BD Only (n=61l 

31.1% (19) 

68.9% (42) 

Total (n=147) 

19.0% (28) _j 

81.0% (119) 


Therapist Error 

Pt. Effort or Ability 

Failed Pre <t Post (ii=77l 

67.5% (52) 

32.5% (25) 

Failed Pre BD Only (n=42: 

57.1% (24) 

42.9% (IS) 

Total (n=119) 

63.9% (76) 

36.1% (43) 

Conclusions: Of the 119 bedside spirometry screening tests performed that did 
not meet acceptability criteria. 63i.9'7c were attributed to therapist error. These 
results demonstrate the need to monitor all clinical services on an ongoing basis, 
particularly where a large staff is involved in performing low volume procedures. 
Identified opportunities as a result of this study include: 1 1 an enhanced monitoring 
of low \i)lunic pHKcdures, 2 1 a continued focus on clinical competencies, and 3) 
the eslablishmeni ot criteria for spirometry to be performed in the Pulmonary Lab 
when acceptable results are unattainable at the bedside. 



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Respiratory Care • September 2002 Vol 47 No 9 

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Tuesday. October 8, 9:3()-l 1:25 am (Rooms 18-19) 

Yons Yu Zhang. MP.. RPFT. Harbor-UCLA Research and Education Instilule. 
Torrance. CA 90502 

Exercise test results arc frequently the standard used to evaluate the efficacy of 
the pharmacological intenention and rchabilitation. The reproducibility and 
variability of the respiratory gas exchange measurement during exercise was 
evaluated in this study for seeking the criteria. Thirteen patients with primary 
pulmon^iry hypertension (PPH). 30 patients with stable chronic heart failure 
(CHF) and 43 patients with renal failure (RF) underwent two progressive incre- 
mental exercise tests on cycle ergometer to a syinptom-limited maxmiuni 
between one and 2f) days. The expired gas analysis was measured by using 
breath-hy-breath. The Peak VO; was determined by the average of Voi at the 
last 30 second of the exercise aiid anaerobic threshold (AT) was evaluated by 
the V-slope method. The Peak VO; (m+SD), on test I and 2. respectively, was 
1.098±0,436L/min and 1 . 1 38±0.450L/min (p<0.(K)l ). The Vo. at AT (m±SD) 
was 0.742±0.2(i7L/min and 0.738± 0.272L/min (p<0.0()l ) respectively. The 
test-to-test reprixlucibility of Peak VO; (r=t).95, SEE=0.015L/min) and AT 
(r=0.92, SEE=0.01217min) was high, the table showed the Peak VO: and AT 
(m+SD) on test 1 and 2 among PPH, CHF and RF groups. There was no signifi- 
cant difference in the Peak Vo; and AT between test 1 and 2 among the three 
groups. There was high reproducible in Peak VO; (PPH: r=0.')4, CHF: r=0.92 
and RF: i^.%) and AT (PPH: r=0.95. CHF: r=d.85 and RF: r=0.95). The inter- 
individual variability of Peak VO: and AT was 9.3± 7.6<7f and 10.2+ 10.0%. 
respectively. These variations were not significantly correlated with Peak VOt or 
AT. This suggested that the variable exercise result was not affected by the 
extent of the exercise capacity. The variation of the Peak VO; was less than 24% 
in the 95% of the patients. Conclusion: the measurement of respiratory gas 
exchange during exercise is an objective and reproducible method for evaluating 
the efficacy of the pharmacological interxention and rehabilitation. For evaluat- 
ing an indiv idual patient a variation in Peak Vo; > 24% would represent a 
significant alteration. 

Peak Vo^ 

Test 1 Test 2 


Test 1 Test 2 


.70±.16 .76±.18 
1.26±.44 1.31 ±.45 
1,11 ±.42 1.14+.44 



.53±.14 >.05 
.86±.30 >.05 
.72±.24 >.05 



Joseph G.DwverBS.RRT . Gary COIdcnburg HA.KK I , ( hnsi.n.i kK I. !usq-,\i 
Kohlman RRT, 

The Johns Hopkins Hospital. Baltimore Maryland 

Introduction: Poor to implementation of pressure monitoring when priming an Rxtracor 
porcal Membrane Oxygenator (ECMO) pump, the tKclusion maneuver at Johns Hopkms 
was performed using visual inspection of tluid advancing appmximately I cm/mm through 
a 12" monitonng line post roller head and pre oxygenator. The priming volume o\ this 
line measured .7cc- This technique review is to determine variation in flow between the 
two priKeUures as well as from person to person, and to show that subjectivity between 
properly trained specialists does not show significant variance. 

Equipment: Stnckcrl Sill occlusive roller head. MeJimnic custom tubing pack consisting 
of class IV tubing. Tyf>on 56.5 raceway, Meiltmnlc .Smcter squared membrane oxygenator. 
Meiitromc ECMOThenn heat exchanger, Sliicki'ri Sill control desk with dual pressure 
monitors, and Transonic^ S\'stt'm\ HTI 10 bypass flow meter. 

Methods: A Sunken Sill RCMO system was .issemhled with the McJlninii cusloni tub- 
ing pack manulaclurcd lor Johns Hopkins The tubing was then primed Ihrniigh 
the crystalloid phase. The Slitrkfrl roller heail was occluded using the pressure readings 
as described in the equipment prtK'edure manual. Direct tlow measurements were taken 
using the Transonic Systems HTI 10 Ultmsanic Bypass Fliny Meter. The readings were 
taken on the outflow portion of the tubing pack's Tyf^ttn Sf)5 raceway at pump flow rates 
ol 1110. 200. 3(X). 4(K). & 500 cc/niin (due to the absence of a patient, fiows cannot be 
reported in cc/kg/min). The occlusion process was then repeated using the fluid advance 
as determined by visual assessment technique for the same fiow values. The entire 
process was then repeated by four different ECMO specialists three times each. 
Results: Total # of measurements =120, Spl, Sp2. Sp3. Sp4 refers to Specialist #1. etc, V 
= visual procedure, P = pressure procedure, Var, = variance between ranges in cc's All 
values are representing the averages achieved by each specialist per range. The pump rev- 
olutions per minute (rpni) lor each flow range measured as follows: l(X)cc/min = 8rpm. 
200cc/min = I5rpm. 30(.)cc/min = 23rpm. 40t)cc/min = 3lrpm. 5flf)cc/min - ,38rpm. 


Spl V/P 

Sp2 V/P 

Sp3 V/P 

Sp4 V/P 

Var,V/P=var, total 



76,3 / 76.7 

74,7/74 7 


2,0/4,0 = 2,0 



LS9.0/ 157,3 






240,7 / 24(1,0 


239,3 /2.W,0 







3.4/4,0 = 0,6 




408,0 / 406,0 


5.3/2.7 = 2,6 

Conclusions: The difference between pressure measurement based values and visual 
assessment based fluid advancement show minimal variation between all specialists 
tested. The largest average variance between ranges was 2.6cc. The demonstrated value 
of this review lies in the confidence that occlusion of a roller head pump can be accurately 
set in the absence of functional pressure monitonng equipment. This provides a proven 
mechanism for setting occlusion manually. Recommendations could be made that special- 
ists be trained in both procedures to assure setting of proper occlusion dunng times when 
quantitative devices are not functional or available. ^-^p ^„ „-,q 


Bradley Demais. RRT, Ste\ en Slaughter. RRT. Eric Feuchu MD. Robert Chatbum RRT 

University Hospitals of Cleveland. Cleveland. Ohio 
BACKGROUND; Dillard ei a! has published equations for predicting PaO: at altitude 
forpatienlswiihCOPDand those with normal lung function. (Chest 1995; 107:352). 
The purpose of this study was to validate the published results and estimate the error of 
predicting values for individual subjects. METHOD: Outpatients with interstitial lung 
or pulmonary va.scular disease and concerns about hypioxia during flight were studied. 
Steady state Pa02 was measured at sea level and duiing a hypoxic inhalation test, 
breathing 15,1*^ oxygen (simulating PaO; at 8.000 ft). Gas was delivered with a 
Downs high flow generator on a nitrogen cylinder entraining room air. FiO; was mea- 
sured with a MaxO: oxygen analyzer calibrated with 5.1^f. \09c. \5.\^c and \9.H% 
precision blended gas. Dillard regression equations predicted PaO; at altitude using 
PaO: at sea level only. PaO: with FEV, 7( predicted or PaO: with FEV t/FVC '/r pre- 
dicted. Error intervals (RespirCare 1996:41:1090) were defined as mean difference 
(predicted PaO: -actual PaO: at simulated altitude) plus or minus 2.659 standard devi- 
ations of the difference (based on Dillard's sample size of 42). RESULTS: Nine 
patients were studied. Results were comparable with those published by Dillard et al. 
Data below give predicted minus measured in mm Hg 

PaOi sea level 

with FEV, 

with KEV|/FVC 

Data Source 

Mean ] SD 

Mean | SD 

Mean { SD 

Our Study 
Dillard .Study 

0.0 5.4 
0.0 5.1 

- 0.2 3.9 
0.0 4.8 

0.4 3.6 
0.0 4.5 

Because the Dillard data were confirmed, we used their results (with a larger n) to 
construct error intervals for prediction error when estimating the PaO: at altitude for 
an individual patient. Intervals indicate range of values for95'^ of estimates at 99^^ 
confidence level: 






1 * 

c n 

■ -1. ■ •- i 

d 5 



Pi03 tea tovM v*i with FEVt wlui FEVITVC 

CONCLUSIONS: CXir rrjsults were nearly identical to those of the Dilhird study and con- 
firmed that including FEV |/FVC reduces piTediction error. However, prt^tlictinns for indi- 
vidual patients may be in error by as much as 1 mm Hg at best. Therefore, if the predicted 
PaOi is marginal, a hypoxic inhalation test may be indicated. OF-02-024 

Rachel Havykins . Sally Gardner. Respiratot7 Therapy Program. Indiana 
University, Deborah Koehl. BS, RRT. Pulmonary Rehabilitation Program 
Manager. Clarian Health, Deborah Cullen, Ed.D.. RRT. Director. Respi- 
ratory Therapy Program. Indiana University, Indianapolis, Indiana 

Background: Given the aging population and an increase of COPD. the 
rise for pulmonary rehabilitation will continue to swell. COPD has 
become the fourth leading cause of death in the United States.' The pur- 
pose of this study was to deterirtine whether pulmonary rehabilitation 
had a positive or negative effect on a patient's perception of dyspnea. 
Rehabilitation consi,sted of exercise, breathing retraining, and patient 
education. Moreover, this study evaluated the effectiveness of 
pulmonary rehabilitation based on the patient's perceptions of dyspnea. 
Methods: The sums of the results for each questionnaire were compared 
pre and post eight weeks of pulmonary rehabilitation using the UCSD 
Shortness of Breath Questionnaire (SOBQ). The SOBQ is a self-admin- 
istered survey that asks the individual to rale their dyspnea from to .5 
during activities of daily living. According Io the authors of the UCSD 
SOBQ, a reduction in a patient's score of 5 or more, an indication of pos- 
itive change, indicated a clinically significant outcome. - Data was gath- 
ered from blinded charts utilizing a convenience sample of 48 patients 
from a rehabilitation program located in a regional hospital in the 
Midwest. All data were entered and analyzed via Microsoft Excel. Insti- 
tutional Review Board approval was obtained for this study. Results: 
619c of patients had a significant positive change indicating a decrease in 
dyspnea. Of the remaining patients, HVr had a negative result consisting 
of an additional 5 or more points post questionnaire. The remaining 2.5'7r 
had no significant change. These results were statistically significant at 
the .05 level (p<.0001 ). Conclusion: Pulmonary rchabilitation does 
have a positive affect on a patient's perception of dyspnea as measured 
via the UCSD SOBQ for our hospital-based rehabilitation program par- 
ticipants. Keywords: pulmonary rehabilitation, dyspnea, shortness ot 
breath, UCSD Shortness of Breath Questionnaire. 

' American Association of Cardiovascular and Pulinonary 
Rehabilitation. Guidelines for pulmonary rehabilitation programs. 
Champaign, 111: Human Kinetics, 1W3. . January 15.2002. OF-02-029 

Respiratory Care • September 2002 Vol 47 No 9 


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RRT . Kevin Hamby, CRT. David Mussctter. BA, RRT, Michael Trcvino. MS. 
RRT. Gar>' Weinstein, MD. FCCP. Presbytenan Hospital of Dallas. Dallas, Texas. 

BACKGROUND: Pulmonary function testing is a common practice in hospitals and 
physician offices across the country. Each facility may reference different sources to 
acquire a set of normal predicted values. The purpose of this study was to compare 
reference standards utilized in facilities within our metropolitan service area. 

METHOD; Eighteen hospitals in the Dallas/Ft. Worth area representing 7.153 
beds were surveyed. Our primary focus was on adult FVC, FEV 1 and DLCO refer- 
ences ranges as these are the most frequent tests performed in both hospital and 
physician office settings. We found a variety of reference standards in use across 
the community of hospitals; some of which were used in combination. For spirom- 
etry. Knudson was used by 729^ of the hospitals, Crapo 17'7f. Morris, Collins. ITS 
and Enright (CHS) were used by 6% of the hospitals. For DLCO, Knudson was 
used by 449^ of the hospitals. Crapo 28%, Miller 1 1%. Morris. Collins. Burrows, 
and Polgar were used by 6% of the hospitals. We compared predicted values 
between different reference standards in a 40 & 70 y/o. Caucasian and African- 
American male each weighing 1 50 pounds at 67" tall. For FVC and FEV 1 the 
American Thoracic Society (ATS) guidelines defines variance as >200mrs 
between FVCs and FEV Is during a spirometry test. 

RESULTS: Variance in predicted values is listed in the table below. We 
compared what our institution uses (Knudson and Miller) against Crapo. the second 
most used standard in our survey. 







40 y/o 
Cauc. male 






3 93 1 1 2,49c 1 


FFVI=3 8S 


40 y/o 
Black male 

FVC=3 73 

FVC=4 0(1 




3.35 (12,40;) 

FEV 1=3,09 

FEV 1=3 30 


70 y/o Cauc. 

FVC=3 50 

FVC=4 Uf> 


DLCO=24 89 


4,2-3 (I7,0''l) 


FEV 1=3 IS 


70 y/o 
Black male 


FVC=3 45 


DLC0=21 15 


3.61 (17.0%) 

FEVI=2 34 

FEV 1=2 68 


CONCLUSION; Due to the significinl variances retlected above, care should be 
taken when interpreting both the volume change, as well as the percent change of 
parameters evaluated. Additionally, an opportunity may exist to establish a 
community benchmark for reference standards utili/ed in the assessment of spirom- 
etry and diffusion for hospital and physician office- based practices. OF-02-1 1 7 


Dr. Bhuvin Dalai *. Dr, Kamal Goplani*. Dr, Pranav Dalai***. Dr. Shahid Surli**. 
Dr. Rasik Parinar**; *A-ssistant Professor of Medicine, Civil Hospital., **Resident 
in Medicine. Civil Hospital; ***Resident in Medicine. V. S. Hospital, Ahmedabad. 
Gujarat. INDIA. Objectives; This study wa-s conducted to check the correlation of 
CD4 count with Manlou.t test (Tuberculin Test / TT). Methods: One hundred HIV 
infected patients not on anti-retroviral therapy were taken into the study and clini- 
cal data and routine investigations recorded. HIV infection was diagnosed by 
ELIS A. which wa-s performed twice for different antibodies. Apart from routine 
investigations TT. CD4 count and CDS count were perforTTied in all patients. TT 
was done by standard Mantoux method. CD4 count was performed by flow 
cytometry. Other investigations were performed as and when required to diagnosis 
tuberculosis & other opportunistic infections. Results: Out of 100 patients, 55 
patients were suffering from some kind of tuberculosis (Group I), while out of 45 
patients not suffering from tuberculosis (Group II), Out of 45 patients 76.4 % 
patients were suffenng frotn Pulmonary Tuberculosis or Mixed Tuberculosis (Pul- 
nioiKiry c^t Extra PuImon;iry), Importance of TT to add diagnostic significance for 
Tuberculosis was limited for the patients whose CD4 count was low (CD4 < 50), 
while there was definite difference in mean TT in patients whose CD4 count > 50. 
who were suffering & not suffering from Tuberculosis. There is also good correla- 
tion between TT and CD4 count. In patients with TT < 5 mm, mean CD4 count 
was 65.10 and 163,59 (Z > 2) in group I (with Tuberculosis) and group 11 (without 
Tuberculosis) respectively; while in patients with TT > 5 mm, mean CD4 count 
was 233,73 and 486,50 (Z > 2) in group I (with Tuberculosis) and group II (with- 
out Tuberculosis) respectively. Expected CD4 count range for the patients of group 
I is 2 - 1 30 & 1 30 - 350 for TT < 5mm & TT > 5 mm respectively. Same way 
expected CD4 count range for the patients of group II is 75 - 230 & 230 - 650 for 
TT < 5 mm & TT > 5 mm. According to regression analysis equation for CD4 
count was derived, which was Y = 25 X -i- 55. where Y = Expected CD4 count & 
X = TT ( mm of induration I. From this equation CD4 count can be very easily cal- 
culated; eg, if patient's TT is 7 mm his/her CD4 count is 25(7) -f 55 = 230, 
Conclusion: TT has some role to play for diagnosis of Tuberculosis in HIV posi- 
tive patients with higher CD4 count. In developing countries it is difficult to 
perform CD4 count due to cost & unavailability, TT can be utilized as a good 
marker to check immunosuppression status in HIV positive patients. Though it is 
very difficult to start HAART from such expected CD4 count, this can be 
definitely utilized to start prophylaxis in developing countries, „_ ^„ ^.. 

A Edgar CPFT, Scot M Witzke CPFT, Paul D Scanlon MD. Mayo Clinic, 
Rochester, MN 55905. 

Measurement of the single breath diffusing capacity using the Jaeger Masterscope 
PFT system ( Yorba Linda, C A ) necessitates a collection tube, which results in a total 
system deadspace ( Vq) of 700 ml. Exhaled gas is analyzed at the distal end of this 
tubing following the standard lO-second breath-hold and exhalation of a 
predetemiined physiologic Vp according to ATS recommendations. We noticed an 
unusual decrease in DLCOsb among patients with previously low values, which had 
been tested using a different PFT system. Hypotheses; In patients with high V/Q 
mismatching the alveolar gas sample at the distal end of the standard large tube will 
be different than at the proximal end resulting in a lower DLCO value. We 
measured DLCOsb in 18 patients with suspected reduced values ba.sed on history 
and 10 healthy technologists (Bio-QC techs) using both the stand.ird tubing and a 
smaller tube with a total system Yd of 350 ml. The patients were randomized into 
two groups where the standard tube was tested first followed by the small tube and 
vice versa to reduce testing bias. The Bio-QC techs were tested twice to satisfy both 
arms of the testing model. Two measurements were made with each tube (4 total ) 
and the mean values of the standard 700 ml Vo versus the 350 ml Vp were used in 
the analysis. A paired Student t-test was used to compare the difference in values. 

18 patients 


DLCO standard 700 ml 
Vp (mean) 

7-4 ml/nimHg/min 
+/- 2.93 SD 

22.5 ml/mmHg/min 
+1- 1.9 SD 

DLCO 350 ml 
Vp (mean) 

9.1 miymmHg/min 
+/- 3.06 SD 

23,0 ml/mmHg/min 
+/- 1.7 SD 

P value 



In all 18 patients the small tube gave a higher DLCO (range; 0.35 to 4.25 

ml/nuiiHg/min, average = 22,9% greater) when compared to the standard large 

tube. The Bio-QC group results varied only slightly between the two tube sizes. 

The small tube results were slightly but significantly higher (range; -1.7 to -(.2.2 

ml/mmHg/min, average = 2,2% greater). These results support the hypothesis. 

The reduction in the tubing Vi, yields a higher result, which in separate analysis 

appears to be more consistent with expected results, 
" OF-02-1 54 



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WITH iQM"'*. Kevin Fallon. PhD - and Sohrab Mansouri. PhD.. Instnimentation Labora- 
tory. Lexington MA. 

Intrtxluction, Instrumentation Laboratory recently intnxluced inrcl!ii;rnt Qiuilin Manage- 
ment (iQM) as an option on the GEM Premier 3fKX) This system .inalvves uhok- hUxxl tor 
bltxxl gases, eleclrolvtes, glucose, lactate, and hemattKril- Cntical Caa* testing sites require 
the highest possible test accuracy without overburdening the already overworked staff. A 
high level of accuracy is not always demonstnible with the popular single use testing 
devices. The IL GEM Premier 3(XX) is a disposable, multi-use i..inndge-based system. Up 
to now. traditional QC methtxis have been iiseil ilunng the c.irtndge's three week use-life. 
IQM eliminates the need tor external controls and the t)tlier labtir intensive QC activities. 
Tliis paper documents the comparability ot iQM quality management with traditional QC 
using statistical comparison of the twomethixis on a series of cartridges. iQM additionally 
incorporates Failure Pattern Recogniliitn (FT'K) that enhances quality control by recogniz- 
ing the pattern asstvialed u ith dnfi .md t)thcr failure conditions and then pnividing 
automatic corrective actions u ith confimiaiion ol ctfecliveness ot the corrections. 
Methods. During the evaluation period instruments were used in normal clinical applica- 
tions. Quality control ampoules were analyzed according to normal laboratory practices 
and statistical rules applied to the data. Simultaneously the IL GEM 3000 was performing 
'constant' checks for any dnft in the calibration and correcting this drift. All data is stored 
for statistical analysis of the calibration dnfls. Internal quality management, which 
paivides both analysis and correction of dnft, (X'curs after each sample and periodically 
during periods of instrument non-use. While external quality control is usually done after a 
calibration, the iQM process control checks are set up to monitor the instrument at the point 
of maximum drift. Pnx:ess Control Solutions are analyzed like a patient sample and the 
values recorded. After analysis any required corrective actions are taken and documented. 
Results, Table I presents daui that supports the fact that the IL GEM Premier 3000 does 
provide tight contri'l olilie sysiem and that sLiiistical analysis shou that the two methods 
arc comparable for maintaining the system tor clinical use 

Table I 
The average of the standard deviations for the internal automatic Process Control Solutions 
and the traditional ampoule controls. Analyles are presented in common units (mmHg. 
mmol/L, etc.) 

pH I PCO: I PC: 

Na' I K- 




Lev I 




Internal Standards 







Lev I 

Lev : 

Lev 3 






External Controls 








Conclusion. iQM on the IL GEM Premier controls the system in a manner analogous to 
standard traditional quality control programs, 

^ ^ ^ ^ OF-02-122 

IL GEM* Premier .3000 CRITICAL CARE* ANALYZER: John J. Ancy . MA. 
R.R.T.'. Kevin Fallon. PhD.-. Sohrab Mansouri. PhD.- 

1. St. Eii/abeth's Hospital. Belleville. IL 

2. Instrumentation Laboratory. Lexington. MA 

Background: Traditional blood gas Quality Control (QC) involves the periodic analy- 
sis of ampouled controls with subsequent statistical evaluation. Resultant values thai 
are within acceptable ranges according to the laboratory's statistical rules 
Intermittently confirm that the instrument is "in control" and available for analysis of 
patient samples. The cartridge based GEM Premier 3000 with Intelligent Quality 
Management (iQM) employs Failure Pattern Recognition (FPR) software, which auto- 
matically and continuously monitors sensors, fiuidics and electronics. FPR also 
provides corrective action without the need of operator intervention, FPR 
continuously assures that the instrument is "in control". After each cartndge is vali- 
dated at start-up with external Calibration Validation Prtxluct (CVP) iQM conducts 
automatic analysis of internal reference solutions to confirm acceptable performance. 
This analysis tKCurs with every sample and periodically during periods on non-use. 
This study tested the effectiveness of the iQM process to produce results comparable 
to a GEM Premier 3000 (reference system). Normal external controls confirmed the 
reference system. 

Method: Whole blood samples were analyzed on the GEM Premier 3(X)0 with iQM 
and on the standard IL GEM Premier 3000. the IL 1745 analy/er. and. for glucose and 
lactate, the YSl 2300 Stat Analyzer. Analytes included pH. PCO;. PO-;. sodium 
(Na*). potassium (K*). ionized calcium (Ca*^). glucose, lactate, and hematocrit. Table 
I displays the average difference between the systems for each analyie. In addition to 
the correlation sludv, \vc confirmed that FPR decreases the influence of some interfer- 
ing substances hv analv/mg blood specimens spiked with Thiopental or 
Benzylkonium Chltmde linally. ue confirmed that FPR could recognize the 
presence of a clol. pertorm a special clot removal procedure automatically, and return 
the system to full operation. The system recognized when the clot could not be 
removed and prevented the analysis of patient samples 

Results; Table 1 demonstrates that the data confirms that the GEM Premier 3(KM) with 
iQM provides high quality data comparable to the reference systems. The PO: differ- 
ences have been demonstrated in other studies to be caused by sample handling proce- 

Table I. 

The average of the differences between the IL GEM Premier 3(XX) and the reference 

systems All values are in common units (mmHg. mmol/L. etc.) 

















0.0 i 














-2 K 


Conclusion: This study demonstrates the effectiveness of the GEM Premier 3(XK) with 
iQM in assuring quality results without operator intervention. There are no statistical 
differences between the test and reference instruments. OF-02-123 


Dennis Yetsko RRT . Damian Craig MS. Michael Gentile RRT. Duke University 
Medical Center, Durham. NC 

Introduction: The medical literature has substantiated ventilator induced lung 
injury with high peak inflation pressures (PIP's), However, lung injury during ven- 
tilation with a manual resusitator bag is not well defined. We hypothesize that use 
of an inline pressure manometer in a manual resuscitation bag would result in more 
consistent PIP's than not using a manometer. 

Methods: We tested twenty Respiratory Care Practitioner's (RCP's). All subjects 
were instructed to ventilate a test lung (PMG 3000. Ingmar Medical. Pittsburgh. 
PA) for two minutes with a PIP of 35cm H20 and respiratory rate of 20 breaths per 
minute using an adult manual resuscitation bag with and without a pressure 
manometer in random order. PIP's were measured by a pressure differential pneu- 
motachometer (NICO. Novamterix Medical Systems. Wallingford. CT). All PIP 
data were blinded from the RCP's. 
Results: Mean PIP's and standard deviation for each RCP were calculated. {Figure 1 ) 

- Manometer PIP 

- No Manometer 

Conclusions: We conclude that PIP's are more consistent when RCP's utilize an 
inline pressure manometer during ventilation with a manual resuscitation bag. This 
may help RCP's avoid high PIP's while using manual resuscitation bag. 


Teisuo Miyagawa'' None KJhara', Hiroki Goshima'. 

'DqjanmCTi of Physical Therapeutics, Showa Univeniiy. School of Nursing and Rehabilitation 

Sciences. Yokohama, Japan; "Kihara Hospital, Ctepartmcnt of Respiraiorj' Medcine, Tokyo, 

Japan, *SECOM Co. LTD. Research & Develop Center. The Fini MedcaJ Team, Tokyo. 


Backgroond: We already fepoitediha our icw respiratory cuff monitor had high reJialMlily in 
AARC 47lh Inicmaional Respiratory Congress The correJalion coefTidaiLs tWwecn chest and 
abttominal cuff pressure, and pjlmonary fundion testing were significantly high in healthy 
subjects and palienis iviifi rcspiralory dscase. The purpose of this study was lo assess the 
chai^ici eristics of our new respiratory cufT monitor, we stuied the dscasc spedfioty and 
reproducibility in healthy subjccis and patients with respiratory disease 

Methods: We analyzed chcsi andatxtminal wave forms of cuff pressure and compared with the 
mcasurcmcnls of pulmonary (unction testing. respiTBiory musdc slrength and chest expansion. 
Twenty-one healthy subjects, seven patients wiih chnctnic asthma, two patients with chronic 
cbstrudive pulmonary disease (COPD) and one palieni with posi TB partictpaled m the iriat. Wc 
also mca,\ure*j several times lo know ihc re prod ucibi lily of this moniiot in ihtsc subjccis 
Results: The repaxkicibiliiy of spirometry and our rcspiralory cuff monitor in healthy subjects 
and rcspiralory dscase patients had signiHcanily ndiabilily (r= 0.58 "^0.97. p<0.005). Cuff 
pressure change in resting ventilation had high correlation not only resting brtathing. l?ut also 
forced expiratory and inspiralofv ventilaiion. Rapid cuff pressures rising in FVC mancuvei weic 
rrmpniTfd in aslhma paiienis (fxrOftOS). ihe negative conrJation cocffidems between c\iff 
pressure and FEV 10. PEFR ai sprometry were in highly significant (r= -0.615, p<rO 001) Rapid 
Luff pmsurcft rising had high uxffiacnts with rcspiralory musde strength snd cuff 
pressure in resting ventilation. FEV, (,and PEFR(r= 0.33 -^0.72, p<0.05~ 0.003), Konno-Mead 
Diagram in respiratory cuff monitor could dacct whether respiratory paiiem of chesi uall and 
abdomen was coortSnaiing ot paradoxical brcalhing. The correlation coefTiaenis bctwom 
cooninaiing breathing paiicm on Konno-Mead dagram and cuff pressure u^ in highly 
significanl. however, inienelai ions hip beiween spirogram and Konno Mead dagrom were r>o( 

Conclusions: Oui simple rcspiralory cufT monilor tiad no load and high reprrxiiabilny in 
pulmonary dscase patients Cuff pressure cjiangc in resting ventilation had high correlation not 
only resting brcalhing. but also forced expiratory and inspiraiory vertilalioa It seemed thai Ihc 
rapid cuff pressure rising in FVC maneuver suggested airflow limitation, 



Respiratory Care • September 2002 Vol 47 No 9 

Tuesday, Octobfr 8. 9:30-1 1:25 am (Rooms 20-21) 



Ccwnmuiiry A Texrhnical CollcgC'Mayp Foundalion, Rocbcstci. MN 

Bi>rk{>rnuad: PiiinnUil'pcdiatric and chronic obsirudive pulmorar>- di*:casc (COPD) paticnls m»y 
rcmiire supplomenlal im'j.'cn adminisiered at low flows. lndustr> notes a standard of ilO*?*. 
Clinical uw, flofagr nndh:*nininf maycfTeci pfrfonnaiiw This invcfligalinn was pCTfomied to 
detemiine if the low-flow devices at our institution are accurate according to industry standards at 
flows ranging from 0.2S-LS Umin. 

Methods: Twenty- four oxygen flowmeters (16 Ohmeda-Madison, WI; 4 Timcter-Sl-l-ouis, MO; 
and 4 l>w7cr Michigan City, IN) currently in clinical use were tested at three ilows: 0.25, LO, L5 
L/min. The nowmeiers were all in working crda and ranged from brand-new to "many" years 
old. Flow settings were made visually by the same person and verified by three observers', the 
CCTta of the indicalor ball was used as the marker. Oxygen flow was meiisured by a hischcr- 
Porlcr Culihralitwi FlowTncter (Bailey-Fischer & Porter. WanniniacT, Pennsylvania) Each 
flowmeter was tested 3 times at every flow for accuracy and the ihrcc indicated values were 
averaged. The oxygen legulaior w^s calibrated to 50 psi usmg a Tinieter RT 200 Calibration 
AnalyzCT (Allied Uralthoire Products Inc.. Si. Louis, MO), The accuracy of ihe Fischci-Porler 
was confirmed at three flows, 0J5, 1.0, and 1.5 Wmin. using a Tissot water-scaled spiromaer 
and a stopwatch. Bland- Altman plots woe used to analyze the data. Statistical agrcrment 
between the flow-metei's indicator ball and the calibratioD flowmeSer measutcments would 
have been cor firmed it 95% ol the datapomis (two standard deviations) were contained 
within a lO^i. margin of error for each flow level. 


0.25 Umin 




0.32 ± 0.05 

1.05 ±0.05 

1.52 ±0.06 

Mam Diff ftom exptdal ± SD of diff 

0.07 ± 0.05 

0.05 ±0.05 

0.02 ± O.06 

Figive I displays a Bland-Altman plot of 0^5 bisin flows. 

Vo,=0 J5 UmIn 


• IH,n.,SO 

• • 



• • 




CoDclusioo: Low-flow flowmeters are not accurate and tend to administer more oxygen than 
indicated al flows less than I L/min. This could be problematic in perinatal, pediatric, and 
COPD patioits. 



Kent Miller. CBET. RRT. Valeric Stevenson. RRT; Elizabeth Grab. RRT 
Rci/.iruivry Cure Drpiinment. University o/Michigon lleaith System. Ann Arbor Michigan 

BACKGROUND: Acutely ill mechanically ventilated patients may require PEEP >5 cm HjO 
to maintain oxygenation, PEEP should be maintained during transport with manual ventilation. 
Disposable PEEP valves are available to use with disposable manual resuscitation bags. 
Although manufacturers may recommend Itiat a pressure manometer be used in-line to monitor 
the desired PEEP level, this study was done to evaluate the performance of disposable PEEP 
valves METHODS: A disposable PEEP vatve from 5 manufacturers was evaluated; all valves 
were new and in original packaging. They were inspected for physical damage or defects. A 
calibrated manometer was connected to the resuscitation bag to obtain measurement of actxwl 
PEEPrcadirgs PEEP of 5, 10, 15.&20cmHjO were evaluated with each valve. O; flows of 
1 and 1 5 L'min were used at each PCO' level. At each PEEP level, the rcsuscilalion bog was 
first compressed 5 times to establish a baseline pressure. During actual measurements, the bag 
was compressed 5 times ever)' 5 seconds and pressure read at the end-exhalation. Valves used; 
Ncllcor Puritan Bennett #135138-00, AMBU tt]99 003 000. Nutec **N3330. Mercury Medical 
tf 10-55330. Vital Signs i/7620. SIMS-Porlex tnmOO\ RESULTS: Evaluation of the recorded 
data demonstrated 3 PEEP valves showing higher PEEP levels then set; 1 disposable PEEP 
valve showed lower PEEP levels then set; and 1 disposable PEEP valve showed PEEP levels 
consisient with what was set. The figure shows data at IS L/min: 

30 T ■ N«"cor Puritan BennM BAMBU D Mercury Mwlleal BNutM: ■VltatStonat 

Set PEEP (cm HM) 

DISCUSSION: The sei PEEP level on a disposable PEEP valve may not correlate with 
measured PEEP levels. Some of the products evaluated revealed a greater than 50% degree of 
vanability in set vs measured. This degree of vaniability may become clinically significant 
and have negative consequences in critically ill patients. Most suppliers indicated on their 
package insert thai an independent manometer was recommended but the strength of the 
recommendation varied. Based on the results of this evaluation we recommend that clmtcians 
utilizing a disposable PEEP valve evaluate the valves pcrformaDce when in use. 



Allan Andrews. MS. RRT . Carl Haas, MLS, RRT; Ronald Dechcrt. MS. RRT 
Cntica] Care Support Serviccj. University of Sfchigan. Ann Arbor, MI 

BACK^lROrND: \ Tniil rcccnily rciting energy expenditure iREE) calculations on ventilated 
paiicnis were dorc using the DeliaTrac II mciabclic can (SensorMedics Corporation, \ orba 
Linda, CAi in conjunction wuh the PB TSt-O (Puiilan Bennen, Inc., Carlsbad. CA). with 
acceptable resulu The PB 840 is now our sumdard veniilalorand it has been suggested that the 
840 does not allow valid REE calculation This study was done to compare the results obtained via 
ihe 7200 and those via ihe 840 METHOD: Ten normal subjects, breathing room air through a 
mouthpiece, had REE's calculated under 5 conditions: no support, PS=5 cm H;© via the 7200 and 
840, and v^ith a VT-0.7 L & f=2 via 7200 and 840. The order of testing was randomized and done 
in duplicate RESULTS The figure shows minimal difference between 7200 and 840 for pressure 
(8 of 10 subjecu}or volHme(7 of Ki) hreji-h'; There W8_<; no significant difference (Wikoxon 
Signed Ranks Test) in REEs for 1) VC-840 vs. PS-840. 2) VC-7200 vs. PS-7200. 3) VC-840 vs 
VC-7200. or 4) PS-840 vs. PS-7200 




















'J vol. MO 

^ Prauufe MO 

■ Vol, 7200 

* P'«M«fB JTtyy 
1600 leOO 2000 :2O0 2400 2S00 2800 

spontaneous REE 

CONCLtSION: Under these lesi conditions l)There were no significant differences m REE's 
between the 840 or 7200, for cither brcatli type. 2) most REE s were higher during mcchanicil 
veniilalion Due 10 ihe imall «ample size and limited variety of ventilator settings, hirther 
uivestigaiion is needed 



Chui-tes McArtlmr BA RRT RPFT . Immanucl- Si Josephs Hospital /Mayo 
Health System. Mankato. MN. Mary E Donlin RRT. Medical Graphics 
Corporation. St. Paul. MN. 

BACKGROUND: This study was designed to evaluate the effect of con- 
tinuous bias flow during mechanical ventilation on a breath by breath gas 
exchange monitor (CPXD. MEDICAL GRAPHICS. St.Paul. MN) with a 
proximal flow sensor. 

METHODS: A gas exchange validator, with a known VO:. VCO:, and 
Vt was interfaced with a Puritan-Bennett S4() ventilator via a standard 
patient ventilator circuit. The CPXD sampled both gas concentrations and 
expired How at the proximal end of the patient airway. The ventilator was 
set in the spontaneous mode to allow delivery of breaths as the validator 
demanded. Breath by breath measurements of VO:. VCO^, and Vt were 
made at various bias flow settings (set on the ventilator) with the follow- 
ing validator settings: stroke volume 1049 ml. VO: 309 ml/min. VCOt 
299 ml/min. frequency 10, duly cycle O.."). Fifty breaths were collected al 
each bias flow setting. 

RESULTS: Measures of agreement (bias ± precision) between the val- 
idator and the CPXD gas exchange monitor are presented below: 




VCO; 1'^^ bias ± 

V't 1 "^r bias ± 


-4,85 ± .19 

-4.29 ± 0.16 

-3,05 ± 0,01 


-4,21 ±0,05 


-2,67± 0,003 


-4,53 ± 0,05 

-3„W ± 0,03 

-2,67 ± 0,003 


-4,21 ±0,05 

-3,63 ± 0.04 

-2,67 ± 0,003 


-4,53 ± 0.05 

-3,63 ± 0,04 

-2,57 ±0,003 


-4,85 ± 0.05 

-3,63 ± 0,04 

-2,48 ± 0,003 

CONCLUSIONS: The CPXD gas exchange monitor with proximal air- 
way How measurement is not affected by continuous bias tlow during 
mechanical ventilalion. 

Partially funded by Medical Graphics Corporation. 


Respiratory Care • September 2002 vol 47 No 9 


Tuesday. October 8, 9:30-1 1 ;25 am (Rooms 20-2 1 ) 


Robert Whitman. Ph.D.. D.ABSM. RRT. RPFT. Michael Garrison. 

RPSGT . Trenton Oestreich, RRT 

University of Kansas Medical Center, Kansas City, KS 

Introduction: Different oximeters with different technologies are used 
in the sleep disorders laboratory to assess level of desaturation during 
sleep related respiratory events. The scoring of hypopneas based on the 
newly implemented definition by Medicare requires that there be a 4% 
or greater decrease in saturation associated with the event. We studied 
two different oximeter technologies to determine if the type of technol- 
ogy would influence the scoring of respiratory hypopneas during sleep. 
Methods: Thirty live patients referred to the sleep disorders laboratory 
for evaluation of possible sleep disordered breathing were studied using 
two common oximeter technologies, a Masinio Radical with SET V3 
technology (M) and a Nellcor N-395 (N3). The Radical was configured 
in the 2-second data averaging mode. The N-395 does not have a user- 
selectable averaging mode. Both oximeters were turned on simul- 
taneously at the beginning of the study and turned off simultaneously at 
the termination of the study. The data from all three oximeters were 
downloaded into PROFOX oximetry analysis software (version PFWS 
OS/99). Both mean saturation and number of desaturations > 47<: were 
extracted from the report and analyzed. 

Results: There were no differences in mean saturation between M and 
N3 (95.2 ± 1.67f. 95.8 ± 1.77f respectively). However, there was a sig- 
nificant difference in the number of desaturations greater than or equal 
to 47f between the two oximeters. The mean number of desaturations 
were 87 ± 84 and 52 ± 5 1 for M and N3 respectively. The Masimo Rad- 
ical detected 699c more desaturations > 4% than the Nellcor N-395. 
Conclusion: The Masimo Radical oximeter detected 61% more desatu- 
ration episodes of > 4% than the Nellcor N-395 during standard 
polysomnography. Thus, oximeter technology appears to have a signif- 
icant impact on the scoring respiratory events and possibly CPAP cov- 
erage by Medicare. 



Kevin U-kiies . RRT. Rebecca Jackvony. RRT Women and Infants' NlCU/Special Can: Nursery. Prov- 
idencc. Rl, 

Introduction: ConverMon lo new monitonng technology is no( uithoui poiential risk, lo the patient if 
the riionilttn, do not perfonii il\ expected and lo the instinjtion if the staff is unsatisfied with the new 
equipment, Ounnslitution. a 60 bed Level HI NICU and Ibbedl^ve! 11 Nursery, made a conversion of 
pulse oximetry technology from Ohmeda and Nellcor technology to Masimo SET technology, which 
claims greater accuracy and fidelity m difficult monitoring condilioas including motion and low perfu- 
sion. ] 2 months following conversion we set out to evaluate the slaff perceptions ot the new nwnitonng 
technology Previous studies, m adults, have clearly demonstrated changes in clinician practice patterns 
following the implemenialion of improved puLse oximetry fmrn Masimo SET technology 1 1 .2] We also 
evaluated our staff perceptions about changes thai may have occurred in their own clinical pracuce pat- 
terns, caring for infants, following this conversion. Methods: We converted all oximetry technology in 
our Level III and Level II units to Masimo SET oximetry 1 2months followmg this cnnveivion. a survey 
(containing 1 7 different questions) was developed lo assess factors related to staff s^itisfacuon. clinical 
practice patterns and patient sal'ety This survey was then adminisleml lo the RNs and RRTs in our 
NICU. 46 cbnicians responded. Questions were designed for clinicians to res^nd to each with cither 
agree, clinically no difference or disagree with the statement. Examples of the questions a.sked follow: 
{ I ) Ease ofapplication of sensor, (lO)Thecombination of decreased false alarms and increased 
confidence in oximetry values has resulted in less dislraclions while caring for other infants, (II) Chang- 
ing to Masimo o,xjmetry has resulted in less handling of 
infants to 'Tix or adjust" senson. in order to obtain n:liable 
saluraUon \ alues, (12)1 have a greater sense of patient 
safety suice changing to Masimo oximetry , ( 1 ^) Titration of 
delivered oxygen concentration to the patient is easier since 
changing to Masimo SET. {14)1 have a greater of 
monitoring reliability since changing to Masimo oximetry. 
( 16) Since changing to Masimo oximetry there has been less 
parental aaxietj' conceming the ftequenc) of false alarms 
and the reliabihty of the monitor and ( 1 7) If i were to trans- 
fer lo another nursing unit, ! would encourage that unit to 
use Masimo oximetry . Chi-square analysis was used to test 
the distribubon of results, p < 0.05 was considered signifi- 
cant. Results: 46 RNs and RRTs responded. The nesulLs of 
this survey are tabulated at left. These results were sigrufi- 
LaniK different from a random disinhuiion. p<0.01- Con- 
clusions: After having used Masimo SET pulse oximetry' in 
our NICU. our staff reports significant staff satisfaction and 
improved pabent safety. They also perceive changes in their 
practice using this new technology, specifically in ease of 
management/titrationofFiO: levels (QuesUons IJland I5l- 
A significantly greater number of staff members agrt;ed that 
they would recommend Masimo oximetry if they were 

Question # 

% Agree 

^c Disagree 




















































transferred to another unit iQuestion 17). 

I , Durbin CG. Roslow SK. Respiratory Care 2000;45(8):985. 

Durbin CG. Respiratory Care 200 1 ;46( 10): 1 1 (H.OF-0 1 - 1 47. 

!. Rostow SK. 


SET RADICAL PULSE OXIMETERS. Mitchell Goldstein. MP '-, Sharon Kemp. RNC 
BSN^. Gilbert Martin. MD'-. Bruce Sindel. MD' % M. Luchia Pemia, MD' -. Clark 
Ochikubo. MD' -. Linda Yang. MD'-. Perpetua Lawas-Alejo.MD' -. and Gilbert Furman, 
MD'-, 'Pediatrix Medical Group, -Queen of the Valley Campus, Citrus Valley Medical 
Center. West Covina. CA 
Evaluation of equipment for the NICU environment is extremely important. Issues of motior 
artifact, lov* perfusion, high intensity light interterence. and necessity of rapid response have 
confounded previous generations of pulse oximeters and required introduction of the newei 
generation pulse oximetet^. Masimo SET has been shown to be superior in clinical trials 
describing its ability to reliably track saturation changes, bradycardia, resist motion artifact, 
and pertbrm in situations with low pertusion. The new Nellcor N-S9.'i has alarm management 
technologies in addition to changes lo the cort* algtinthm designed to enhance pertomiance 
Of pnniary importance in tlie use of these oximeters is the perception of how each perlorms 
rtlalive to the clinical expectation of the nurses, respiratory therapists, and physicians using 
the technology. To demonstrate whether prixluct impnivemenLs in the Nellcor N-595 would 
give nse to perceived clinical supenority to Masinio SET technology, both manufacturers 
were invited to demonstrate their prtxluct in a 40-bed level 111 NICU that had used Nellcoi 
technology based oximeters for at least 15 years. Both manufaclui^rs were then invited to 
submit their latest oximeters for clinical evaluation over the course of a week's penod ol 
time, consecutively but non-concurrently. During that time, product repnssentatives from 
each company were permitted lo give in-services to the nursing and respiratory staff. The iwu 
physician groups were inserviced separately. During the trial of the Nellcor N-595. several 
staff members insisted on having the Masimo SET pulse oximeter continued on one patient 
who was "extremely diftlcult". At the conclusion of the product evaluation, each company 
gave separate evaluation forms with different inventory items to the nursing and respiratory 
staff. Physician response to the evaluation was elicited separately. A draw ing for a prize was 
promised for respondenLs to the Nellcor survey. 26 responses wens obtained for the Nellcot 
N-595; and 3 1 . for the Masimo SET. In analyzing responses, txith the Masimo SET and Nell 
cor N-595 elicited marks at the upper end of the checked inventories, although most of the 
inventories were dissimilar and not comparative. However, in reliability and accuracy of dis- 
play or correlation oi oximeter with other data, the Masimo SET was judged to be superior. 
{p<0.05) Although both manufactuters supplied areas for comments, only the Masimo SET 
was given separate unsolicited praise for its clinical feature set. Of the submitted written sur- 
veys. 75% exalted Masimo SET for its improved pertomiance with motion. low perfusion, 
transport, sensor durability, or day-to-day clinical use. Only 1 2*r of the stalT indicated any 
separate ptjsitive comments after filling out the Nellcor survey. Although an impaivement ol 
the N-595 over Nellcor's earlier nuxlcls was noted, these staff members ultimately indicated 
a preference for Masimo SET. After both evaluation periods, in a separate survey, preference 
for final NICU purchase was elicited frt)m NICU nurses. Respiratory staff, and physicians 
(n=28) ^y/i of a*s[>ondcnls preferred the Masimo SET technology. Despite improvement in 
monitonng promised b\ ihc Nellcor N-595. the Masimo SET Radical was selected on the 
strength of its clinical perfonnance. 


Effects of Positioning on the Reliabihty and Effecti% eness of the 
Vortran Automatic Resuscitalor 

Sean Mcllor. BS RRT. Dean Holland. RRT. Robert Esietler. RRT. 

Jackie Boynlon, RRT. Kenneth Ha« kms. BS RRT 

Parkland Health iuid Hospital System. Dallas. Texas 

Department of Respiratory Care 

Introduction; The Vortran Automatic Resascitato^^V.^R)(Vortran Medical Technology' I. INC 
Sacranienlo. CA ) is a single patient, multiple- use resuscilator Medical lileralure suggcsLs that the V.^R 
provides reliable and consistent vcntilalors suppt^rt. We will evaluate the etTecLs ol positioning on the 
reliability and effecuveness of the V'AR. Methods: Ten VARs (Model RC with monometer) were 
divided inlo two groups each consisting of five V AR's. Each VAR was evaluated using Michig;tn 
InsinimenLs adult lung model interfaced with PneuView soft\% are {Michigan Instruments, INC Santa 
Monic;i. CA I Group ,A was positioned honzontally as illustrated in the V.AR operation manual w hile 
Group B wa.s posiiioned vertically .W\ VARs were connected to the lung model with a » S endotracheal 
lube it ri I ;ind an adull hygmseopic condenser humidifien .■Allegiance Healthcare. McGaw Park, ILl. 
Lung compliance wa.s fixed at 60ccyciiiH20 throughout the e\aluaUon Each V,-\R was set "Aith KKJ^ 
FI02entrainmenl and connected lo.ihigh-llin\ oxygen tlowmcicrsciaiaFlow Raic(FR)30 Ipm 
VARs were then set lodeli\er Peak Inspiratory Pressure iPIP) 20 and Respiratory Raic (RRl 12 
Minute Volume iMVi, Inspiralorv -Iinie (l-Umel, PIP. and RR data was collected in ten minute intervals 
tor a penvxl ol 24 houiN Results \^ere pi^isied in a Trend Report \ la PneuView software Results: In 
Gamp A. three out oIti\c \ .-\k s tailed lo tngger lor the duration of ihe 24 hour evaluation pentxl. One 
VAR fiuled at two hours ;ind another failed at three hours: hoth tailed lo trigger again for the remainder 
of evaluation The third malfunctioned atone hour and tony niinulcs Failure consisted of the VAR 
reaching PIP and llien tlullcnng at PIP lor ten minutes ll then resumed nonnal operation when at six 
hour. It failed In ingger for the duratii>n of the evaluation. In Gr^iup B. all five ot the \'AR's inggered 
Ihn)ughnuiiheduniiioiiorihe 24 hour evaluation. Fourof the five V AR's maintained paramelers set al 
initialion of the evaluation The fifth VAR maintained parameters for 23 hours, the RR then decreased 
Imm 1 2 to 6.8 for a penod of 30 minutes. It should be noted that the fifth VAR completed the evaluation 
penod In the table below is a summary of data collected and analyzed by PneuView software, 


GROUP A - Ranee 

GROUP B Ranee 


4.J - :i 5 

ii; - :i s 

l)(l- VVi 

s 1 n'* 

RR Ibpin) 

6.S- 12 8 

I-linic (sect 

0.7 - 5.0 

2.1 • 2.6 

Experience: Our initial study was designed to evaluate the effectivencvs of the VAR at diflereni lung 
compliance Initial data wa.s gathere*d using a compliance of 6nccycmH20 When set compli;ini.r was 
changed lo 20. .10. 40. or 50cc/cmH20 the VAR repeatedly failed to tngger with initial set paramelers 
(FR 30, PIP 20, RR 1 2t, At that time we noted thai Ihe data we collected changed as the pitsnion of the 
VAR was miinipulatcd, Asa re'sult wc decided loevalualeposiuoning and the effects on the reliability 
iind effectiventss of the VAR, Conclusion: Our preliminary evaluadon has denwnstrated that ase of the 
VAR presents some significani clinical concerns Our pnmiuy c-onccm is the inconsistent pertomiance 
ol ihc de\ ICC under holh lesi conditions We suggest ihal al minimum ail patients placed on the V,-\R he 
monitored conlinuouslv Ilie grav iiv dependenl nature of the VAR suggests unreliable pchonnance, 
especiallv when the device is posiiioned honzontally If the manufacturer is able to overeomc reliability 
ivsuos then \vc suggest ih.ii lung compluuwe relalcd liinilations j1mi be addre-ssed The VAR. with modi- 
ficatinns, cnuld he an altem.ilive toother lormsof ventilalorv il necc"s.sar> Further research is 
needled in order lo evaluate the reliability and effectiveness of the VAR in low compliance sccnanos and 
in use with PEEP valves. Pnilocol nuxlifications which address positional oneniation of the V'AR are 



Respiratory Care • September 2002 Vol 47 No 9 

Tuesday. OCTOBF-R S. 9:30-1 1:25 am (Rooms 20-21 ) 

SVSTKM: A CASK STIDV Sii/armc M Durning HS, R R !'. Rodnllo (.Iodine/ 
MD, PhD. Limlu A, Napoli. BS. RRT The Children's nt PhiUidclphui. 
Philadelphia. PA 

This patient is a 3-kg. Baby girl with a diagnosis of single venlriele physiology 
\\ ith possible pulmonary atresia. .She was adniilied to our Cardiac Intensive Care 
Cnit iClCC)ai 12 hours ot life. The initial ventilator settings were SIMV Pressure 
Preset mode. Rate of 16. Peak inspiratory pressure 26emH:(). Fi02 ,2 1 . PEEP 5 
emH;0 and Pressure Support of 5 cmH;0. The patient underwent eardiae 
catheterization on day two of life and was diagn(*scii with heierota\\. asplenia, 
infradiaphragmatic total anomalous pulmonary \enous rciuni iTAPV Rl and 
coarctation of the aorta, (.)n day three of life, the patient was taken to the cardiac 
operating room for complex repair of TAPVR. pulmoiiars artery patch plasty, and 
placement of a central aorta lo pulmonary shunt. 

The patient had a 5.0 Kr. Neotrend-L compatible Argyte umbilical artery caiiieier 
placed intraoperatively and a Neolrend-L continuous blood gas monitonng sensor 
was inserted \ia the CAC postoperatively in the CICl', Multiple comparisons 
were made between blood gas results fmm the Blood Gas l.jh and the Neolrend-L 
continuous blood gas monitor with comparable results. Posioperalively. the 
patient demonstrated a labile pulmonary vascular resistance, which was treated 
w Ith mild hy per\ enlilalion and nitric oxide therapy to maintain adequate 
pulmonary blood tlow. 

Postoperatively, the patient's mechanical ventilation was weaned by physician 
goal-directed orders for pH. PCO: and PO: utilizing the Neotrend-L monitor. In 
addition, continuous blood gas monitoring enabled us to expedite the process of 
weaning the patient from nitric oxide therapy 


The Neotrend-L Continuous Blood Gas Monitor allowed the bedside clinicians to 
titrate the patient's ventilator settings and nitric oxide therapy w ith "real-time" 
results at the bedside. Further evaluation is needed to determine appropriate use 
and application of this technology in the pediatric population. 

TTie Diametncs Continuous Blood Gas Monitoring System and technical support 
was provided by Philips Medical Systems, 

Naturally Friendly 

Respiratoiy Therapy 
Education Coordinator 
fe Respiratory Therapists 

ro Icam more about our organization and these 
opportunities, visit our website at «\vu. 
Jualifications may be submitted online or to: 

Borgess EmplovTnent Office 
I52I Gull Road 
Kalamazoo. MI 49001 
-a.\: (269)226-5330 

v'isit our booth at the AARC Comention in 
Pampa. Florida. Booth #1040. 

3orgess Health Alliance includes 
Borgess Medical Center, a 424-bed tertiary- 
nospital. six regional hospitals, nursing 
lomes. and outpatient clinics throughout 
iouthwcst Michigan, 






IngM.'XR Medical 

Smart Solutions for 
Lung Simulation 


and Testing 

and Flow 

IngMar Medical ...A New Vision for Respiratory Care 

Tel: 8()0-S8J-')4l(i Fdx: 412-681-8404 

Circle 1 55 on product information cord 
Visit AARC Booth 704 in Tampa 



Circle 108 on product Information cord 

Respirators Care • September 2002 Vol 47 No 9 


Foundation Enteiprise.s, a nationwide respiratory 
recruitment company, has openings for: 


Charge Therapist 

Directors, Managers 

Polysomnographers, Sleep Lab 


For more information, contact: 

Bryan Smith 
Bryan. foundation @co.\inet. net 


Travis Nunley 
Travis. foundation @co.\inct. net 


Fa,\ vour resume for consideration to: 


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Circle 152 on product information cord 10^9 
Visit AARC Booth 647 in Tampa 



for the 

2003 International Respiratory Congress 



The AARC Program Committee is now accepting proposals for programs to be presented at the 
2003 Congress. To submit your proposal, please follow the instructions in the RFPs brochure 
found in the 

• Registration area at the 2002 International Respiratory Congress in Tampa 

• October 2002 issue of AARC Times 

• AARC website ( 

Proposals must be submited by 
Dec. 31, 2002 

More AARC Education Programs in 2002-2003 

For all information, visit the AARC website,, or call (972) 243-AARC (2272). 

ALL programs are accredited for continuing education credit (CRCE). 

Polysomnography Registration Preparation Course 
Nov. 9-10, 2002 • Dallas, Texas 

Designed to assist respiratory therapists seel<ing to earn the Registered Polysomnography Technologist (RPSCT) credential 
awarded by the Board of Registered Polysomnography Technologists (BRPT). The course is tailored to the BRPT examination 
content outline, and designed to build upon the existing knowledge base of credentialed respiratory therapists by focusing on 
polysomnography testing preparation, procedures, and record scoring. 

Asthma Education Certification Preparation Course 
Dec. 7-8, 2002 • Cleveland, Ohio 

Developed to assist respiratory therapists preparing to take the credential awarded by the National Asthma Education 
Certification Board (NACEB). The course content is designed to the NACEB examination outline and will build on the existing 
knowledge base of credentialed respiratory therapists. 

Patient Assessment Skills Course 
April 4-6, 2003 • Atlanta, Georgia 

One of the barriers to the successful implementation of respiratory protocols is staff confidence in their patient assessment 
skills. This course is designed to improve the skills of respiratory therapists in the inpatient setting. 

Summer Forum 
July 25-27, 2003 • Orlando, Florida 
Contemporary Hotel in Disney World 

The annual event specifically designed for managers, supervisors, and educators, A perfect family vacation combined with a 
unique educational experience. Get your CRCE hours and have some fun in the sun! 

TUKSDAY. OCTOBKR S. 1:30-3:25 PM {Rooms 20-21 ) 

Transmission nl'N ihrutions from the Auipellu \irHa\ Clearanct* Dexicc 
During the Kxpiralon Phase of Mechanical Ventilation 
kathlcL-n Dcakms RRT . Julie Dif-ii>re BStE. Timolhv Mvers BS. RRT jnd Koberl 
Chalbum. RRT. lAARC. Rainhow Babies and Children's Hospital. CIc\ eland, OH 
Introduction: Ptisune e\pir;itor> pressure (PHPi is used to taeilitate mobilization 
ol retained secretions and re-e\pand areas ot ateleetasis, Tlie Acapella i DHD 
HealthCare Corp i is a How operated oscillating PHP de\ ice designed to enhance 
secretion removal using a counterweighted plug and magnet that interrupts expira- 
tor\ (low through a pivoting cone at frequencies (fl 0-30 H/. Vibration sensations 
during exhalation reportedly ha\e been felt \\ hen the Acapella is applied lo the 
cxpinilory vahe of ventilators. The purpi>sc of this siud\ is to determine if the 
Acapella oscillations produced are transmitted lo the patient wye dunng the expira- 
tory phase of mechanical ventilation. Methods: In this bench study, a Bird VIP 
ventilator with infant \entilator circuit was cimnecied to a 4.0 mm endotracheal 
tube and an Infant Star Test Lung to simulate infant ventilation. Sellings ol 
Volume-Control SIM V. f = 25/iTiin. PEEP +5 cmH;0. Vt 50cc. sensiti"\ iiy -2 cm 
H:0 and a flow 6 L/min. Baseline measures of Flow. PIP. and PEEP were obtained 
via a Fleisch pneumotach and Borded Cell National Instruments PC-LBM- 16 Data 
Acquisition Svstem with Labsiew Version 12 soltware isampling speed of 500H/). 
A \ov. flow Aeapellu (<l>l-/mm» was placed on the expiratory valve of the ventila- 
tor. Oscillation frcquencv. amplitude, and auto PEEP were measured at the wye on 
exhalation at two Acapella sellings: minimum I-) and maximum ( + 1. We repealed 
the prcxedure using an aduli ventilator circuit connected to a 7.0 mm endotracheal 
tube, and Adull/Pediatric Test Lung Mtxiel (Ingmar Medical Inc.) set at normal 
resistance and compliance with a high flow Acapella (>1.*> L/min) attached to the 
ventilator expiratory valve. Settings of Volume-Contrtil SIMV. f = 12/min, PEEP 
+5 cmH:0. \'j 5(K)cc. sensitivity -2 cmH:0 and How 30 L/min were used. Results: 
During the infant simulation at I -) and i-t-l Acapella settings, oscillation f = 26 Hz 
with amplitude t>f 2 1 cm H;0 and no auto PEEP. Using the adult simulation at (-) 
seitinc. f = I I H/. amplilude ."^OcmH^O. At (-i-) setlins. 
f = }?• H/. amplitude = 1 7 cmH:0 with aulo PEEP = 1 2 cmHiO. Oscillations 
caused the ventilator to auto trigger continuously, requiring the sensitivity to be 
reduced. The graphs below show representative waveforms. 

Adul- High Frvgucncy 



Conclusion: An Acapella placed at the expiratory valve of a veniilalor transmits 
oscillaiit>ns to the palienl wye on expiration during infant and adult mechanical 
ventilation, but caused auto PEEP and sensitivity problems. These issues should be 
addressed before considering use of the .Acapella during mechanical v entilation, 


1 hi- KfTccl i>f \ i-nlilator t'irciiil l.t-nRlh on IK>liMTt'd \ nlumv during High Kri-»iuiiit> 
Ostilliilnn \ tnlilatiun. J I)ii\ics BS MA RRT. M. LcoruiJ RKf. G. Ahcani MU. -M GciUilv 
KKI, N \l.iJni>a-MD. 

IniriMlui-iinii: I'lsinn displacement during high frequency oscillatory veniilalion (HFOVj dctcr- 
iniiK-v Ilk- pr^;^surc and \nlurnc chanjics in ihc ventilator circuilr\' However, circuit compliance 
nia> ha\csiiznirii.:inlclfcclson ihc iransmissum of ihcsc pressures and volumes imo the lungs 
ot palicnts. One faclor affcclini: cifLUil compliance is circuit Icnglh. 

U> polhcsis: Wc hvpoihcsi/cd ihal the use of a longer ventilator circuit would ihc lidal 
\nliiine delivery to the paiicnt during HFOV. 

Methods: A Scnstirincdics .IKMIb oscillator was attached lo an Ingmar PMG .^(HMI test luny 
iliiuniar Medical. Lid, I'lllshurgh. Pa,). Compliance ol ihe lest lung was sel at 20 ml/cm H:0. 
lesisiance lo mimic .1 l>pical palienl wuh acute lung injurj-. Wc used Ihe following sellings: 
l-iO; = 0.2 i . mean pressure = 1 5 cm H20. delta pressure = 70 cm H2C). and 1 time ')i = ^^'i 
Two veniilaior circuits were used; the first was 5 1 inches long wiih a circuit compliance o( 0,.S 
ml/cm H;0 (long circuit): the second was .18 inches long with a compliance ol'O..^ cm H:0 
isliorl circuit 1, I1eli\ered tidal volume to the test lung was determined with oscillator bias flows 
of 20. M) 40 and 50 Ipm. and breathing frequencies of 3. 4. 5 and 6 H/. Data were collected 
over a .^-minute lime period for each combination of bias flow and frequency. For each combi- 
nation of bias How and frequency, lidal volume delivery with each circuit was compared by 
two-tailed paired t-tests. Significance was defined as p<U.05. 

Results: Data analysis showed a statistical significance (p<. 0001) in ml of tidal volume deliv- 
ery with differing lenglhsof oscillator tubing under all leM conditions (Table), 

Bias Flow - 2(1 



Bias Flow - V) 





II 1 




II 1 




5 Hi 












Bias Flow - 40 



Bias Flow - 51) 


She in 



1 14 



















6 Hz 



Conclusion: Longer oscillator circuits with higher circuit compliances serve to dampen tidal 
volume delivery during HFO. This has the p<Mential to affect gas transport. While Ihe use of a 
lonjjer oscillator circuit may aid m convenience around the bedside (since the oscillator can be 
positioned farther away from the bedside), clinicians must be aware of the potential loss of vol- 
ume to the lungs as a consequence of longer circuitry. 



( ALS) IN A LI NG MODEL. Da\id L \ ines. MHS.RRT . Anita Alvarez. CRT. Salvador A 
Da\o. CRTand Jay I Peters. MD. Respiratory Care. The Cniversitv of Texas Health Science 
Center. San .Antonio. Texas. Background: The purpose of this suidy is to determine if differ- 
ences exist in tidal volumes (V't) and peak inspiratory pressure (PIP) at the airway and between 
the lungs when using continuous mandatorv ventilation (CMVi, CMV with leak compensation 
tCM\'-LC). CMV \\ith .AutoRow (CMV-.AF), iind pressure continl ventilation iPCV) in .\LS, 
Method: The .ALS was created in a iwo-cniiipanmeni mechanical lung model (Michigan 
Instnjmenis Inc.. Grand Rapids. MI \ by inserting a 3 (t mm catheter in the left lung. Inspired Vj 
expired Vy. and PIP were measured at the beginning nf the airv^ay using a Ventrak 1550 
iNovametnx Medical S\ stems. Inc.. Walliniiion. CTiaiid belore both lunes using aC02SM0 
Plus (Novametnx Medical Svsiems. Inc . Wallingion. CT). CMV. CMV-LC. CMV-AF. and 
PCV wereset todelivera VTof40fJ. 6fX)andS0(")mLaiarateof l5bpmon theEvita4 ventila- 
tor (Dniger Medical. Inc.. Telford, PA.i. All vanables were collected for all modes on an inspi- 
ratory to expiratory ratio of 1:2. 1:1. and 2: 1 w ith and without a leak in the following lung con- 
ditions: compliaiKeof0.50 and 0.20 L/cmH20 vMthan airway resistance of 2.7 cmH20/L/sec. 
and a compliance of 0.50 L/cmH20 \\ithanairvvay resistance of I7.6cmH20/L/see. Results: 
The foliov^ing results are means i SDi for data collected under all conditions. There were no 
significant differences between CMV. CMV-LC. CMV-AF. and PCV without a leak. Inspired 
Vt was siiinificantlv higher dunnc CM\'-LC (764 ± l97mL) and CMV-.\F(764 ± 2IOmL) 
with a leak compared to CMV (548 ± 149mLi. CMV-LC (558 ± 15lmL. CMV-AF (555 ± 
1 59mL ). and PC\' 1 568 ± 1 57mL 1 without a leak, and CMV ( 552 ± i 48mL) with a leak. 
Expired Vx was significanlK hmherdunnizCMV without a leak (547 ± 150mL) and CMV-LC 
(509 ± I47mL. 557 ± 152mLi, CMV-AF (",502 ± 148mL. 567 ± l60mLi. and PCV (470 ± 
13lmL. 574± l6ImL) with and without a leak compared lo CMV with a leak (352 ± I ISmL). 
Right lung inspired V't wassignificantiv hieherdunnuCMV without aleak (240±78mLi and 
CMV-LC (271 ± 85mL. 249 ± 77mL).'CMV-AF (269 ± fUmL. 254 ± 81mLi. and PCV (240 ± 
SOmL. 255 ± 84mL) with and w iihout a leak compared to CMV w ith a leak 1 1 72 ± 74mL). 
Right lung expired Vj wassignificantiv hisher dunng CMV without a leak (235 ±73mL) and 
CMV-LC 1 362 ± 8 1 mL. 242 ± 73mL).'CM V-AF ( 253 ± 8 1 mL. 240 ± 76mL ). and PCV ( 234 ± 
74mL. 248 ± 78mL) with and without a leak compared to CMV with a leak ( 173 ± 63mL). Left 
lung inspired Vt was signiftcanily higher dunnc CMV-LC (489 ± 1 27mL). CMV-AF ( 503 ± 
l42mL). and PCV (440± I41mLi wiih a leak compared to CMV (359 ± 91mL) with a leak, 
and CMV (286 ± 79mL). CMV-LC t289 i 80mL). CMV-AF (29? ± 84mL). and PCV (299 ± 
84mL) without a leak. Left lung expired Vt wassisnificantlv higher during CMV (281 * 
75mL). CMV-LC (2W ± 76mLi. CMV-AF (286 ± 79mLl. PCV (293 ± 80mL) without a leak 
compared to CMV ( 162 ±6lmL). CMV-LC (220 3:62mL). CMV-AF (219 ±62mL). and PCV 
(208i55mL)withaleak. Left lung expired Vr wassignificantiv higher dunng CMV-LC (220 
± 62mL) and CMV-AF 1 2 1 9 ± 62mL) w iih a le;ik compared to CMV ( 1 62 ± 6 1 mL i with a leak. 
There were no significant differences between PlPai the airway or between the lungs with or 
without an air leak. Conclusions: When a teak was present. CMV with leak compensiuion or 
AutoFlow increased inspired V't to maintain a significantly higher expired \'j in btHh lungs 
compared to CMV w iihout leak compensation or AutoFlow . In the presence of an air leak. 
PCV increased inspiratory flow to maintain the set inspiratory pressure, which resulted in a sig- 
nificantly higher inspired Vt in both lungs and a significantly higher expired Vt in the nght 
lung compared to CMV w iihout leak compensation or AutoRow . These findings suggest that 
CnTv w iih leak compensation. CMV w ith AutoRow or PCV may maintain bener gas exchange 
compared to CMV w ithout leak compensation or AutoRow ^p «« .. en 


Dawn Burks RRT . Jason Higgins RRT. Grant OKeele M. D,. 
Surgical/Trauma ICU. Parkland Hospital. Dallas. Texas 

Inrrodiiciion: High Frequency Ventilation use in a patient with pulmonary edema and hypoxia 
that lead to repeated codes requiring ACLS intervention 6 times in approximately ! 2 hours. 

Case Summary: A 62 yr old Hispanic male was admitted to the Parkland ER. with leg and pelv is 
fractures on a lOO^i no n- re breather mask. His medical hislor)' was diabetes x3yrs. He was 
hypotensive and given niulliple fluid boluses and blood products. Seven hours later he appeared 
in obvious respiratory distress, sals dropped, and BLBS revealed crackles ihrouglioui. An ABG 
indicated PaO;of 53mm Hg. The palient was iniuhaied and a Svvan-Ganz catheter was placed 
The patienl's initial Cardiac output iCOi was 2 dlUmin and SV02 60mm Hg. Hypotension 
cttnlinued to be managed w ilh fluids and blood products. Four hours later the patienl's HR 
dropped to 34 bpm. BP 40/30. pulse, -ACLS proltKols began w ith posilive results and vasopres- 
sors were siartcd Sixteen hours post arrival, despite aggressive ventilator management, serial 
ABGs' revealed no significant improvement in Pa02 and Swan readings show a slight increase 
in CO (3,4L/min) and an SV02of 57*S. Patient's fluid balance was positive I8L. urine output 
was minimal, and the patient continued to require ACLS intervention for the next six hours. 
Over the next fourteen hours, the patient experienced fulminating pulmonarv- edema despite 
PEEP levels exceeding 25 cm H20, ETT suciioning at this time only decreased mean inira-tho- 
racic pressures and allowed for worsening pulmonary edema. The decision was made to place Ihe 
patient on HFOV 3I00A with these initial settings: MAP 37. Power 10 with a resultant 
.Amplitude of 60. HZ 5. 1-timc *:? of .50 . and an Fi02 UK)n. The patient's oxygen index at this 
point was 76 which was .^0 greater than the IflO'^r falality group observed in the Fort HFOV 
study Additionally, no significant improvement m ABC's or Swan readings were noied and 
ACLS interveniion was still required Over the next three hours, while the initial CXR allenipl 
was not tolerated, vital signs began to improve. There was no more evidence of pulmonar) 
edema m the ETT Cardiac output increased lo (4.KL/mini. SV increased from 19ml/beat lo 
2Hml/heat. and SV02 climbed to 71*^^* The patient's unne output was increasing and vasopres- 
sors were weaned. After eight hours on HFOV a second CXR was successful and revealed the 
palicnt's diaphragm at TIO in the nghi lung mid-clavicular representing overdistension. Conse- 
quentlv. MAP was decreased to 35cm H:0. One hour later the ABG showed 7.48/3 1/157/23/- 
2/02 sat 97^^. At this time MAP was decreased to 30cm H20 and the Fi02 decreased to 60'S 
with a follow up ABG showing a Pa02 of 121. Ventilalor weaning continued as blood gasses 
and diaphragm placement indicated. Over the next 24 hours all cardiovascular dnps were discon- 
tinued. Vent seuings weaned as clinically indicated by blood gasses and diaphragm location 
shown on CXR. The patient relumed to conventional ventilation approximately 72 hours after 
initiation of HFOV. and was transferred lo the n(K>r several weeks later. 

Piuussinn: This ease may point to another indication or benefit of using HFOV where high 
MAP'S are required. The patient's pulmonary edema was so severe that it was impossible to oxy- 
genate him conventionally His in)uncs and tenuous hemcxlynamics did not allow for prone posi- 
tioning The immediate effect of higher MAP may have been a large factor in treating his hypox- 
emia and thus ending his need of ACLS, It seemed that some hemodynamic benefits may have 
been gained as ihe palieni's cardiac output appeared to increase and improve gradually after his 
placement on HFOV This case mav show that HFOV could be used in a proactive role in the 
correct palient ptipuhition as opposed to the rescue mode usually used ItxJay. nF-02-146 



Tuesday. Octorfr 8. 1:30-3:25 pm (Rooms 20-21) 


Jennifer LX- Ln Gjr/;i KKT . J^isoii Uitiyins RR I . IX-an Holland RR i . Cirant O^Keek- MD MPH 
IX.-panincnK tit Rcspiralon' Care and Surgery. Parklaiul HcjIiIi ami Ht>spilal Syslcni, Dallas, TX 

inlriiduclinn: High HrequL-ncj (Kcillaiory Venltlaiiun (HKJVi and High Frequency Percussive 
Vcnlitalmii I Hf-PV) are s|K'cialJ/ed nuKles ot ventilaliuii, HFOV is dUcii used as a rescue nunle ol 
veiiiilalioi) uhen convenlional vcnlilalioti fails lo prux ide adequate oxygenation (or lung 
rei.niitnienl( HFPV was developed to lacililate the a.*nio\al ot secretions and sloughing from 
injured lung tissue, study in which hoth tliese nKxles of ventilation were utilized 
with success. 

Case Summary: A 30 year-old Hispanic mate, unrestrained driver involved in a high-speed motor 
sehicle collision resulting in major hlunt chest and ahtloinnial trauma was initially transported to an 
outside hospiial and miuhaied Six hours laier the palicnl was translcrred lo our facility Shortly 
after amval. ihc patient was taken to ihe OR Ini licnio[xriHoncuin wiih heim>d>nannc insiabihly 
Piisio|XTali\e diagnoses included a grade IV splenic laceration, luutliple grade Ml liver laccralioiis. 
Icli puiiiionarv .^oiiiusion. and left pneumothorax. The patient left the OR wiih two chest lut>cs on 
the Ictt side and an open abdomen Post surgcrv. ihe patient's PaO^ was 52inniHe on the following 
%cnlilalor settings PC ( ACl. PIP4?cmH:0, PI.FP IOlmiH^O. RR :(i, FIO- ol IIH)^;. The patient's 
WHC was 7 2a PEEP inlleciion curve was |ierliinned Results were inconLlusive secondary to air 
leaks ji chest tube sites The patient continued icKletcrit irate over the next V4 hours in spite of all 
clloiis to overcome an increasing volume loss at the chest tube sites The patient was placed on 
HFOV w ilh initial settings of MAP 2H. Amplitude 55. Hcrl/ S. Rower 7 4. Bias Flow 30. FiO; 
UHl';. Dunng the tlrst 24 hours of HFOV. the patient's P/F ratio improved from .52 to 224 and the 
patient's chest x-ray showed improved lung expansion B\ hospital day four, the air leaks had 
resolved and Ihe pa'tient was placed on PC (AC). PIP 3(VniH:0. PEEP'7cmH:0. RR 20. FIO; f\iV7, 
On day 5 the chest tubes wen; placed to water seal and the patient was placed on AC. RR 14. Vj 
7.S0. PEEP 5cTnH:0. FIO; 50*:'^ . The patient's WBC count increased on day 5 to 19.2. On day 6. 
one chest tube was removed. A pneumothorax was identified on day 7 and Ihe remaining chest lube 
was placed lo suction. Over the next nine days, his WBC count increased to 64 in spite of 
aggressive ircaliiient with antibiotics and anii-kiiigal agents A chest CT on day 16 identified a left 
lower lobe consolidation and a pulnioiuii'\ absLcss that icquncd a CT guided dram placement. On 
dav l,s. the paticni was diagnosed wiih a ncLToti/mg piR-umoiiia Thoracic surgery was consulted to 
jierlnmi a left pneumnncLioinv or lobcilomv Surgcrv was postponed due to patient instability. 
HFP\ was initiated to lacihtate secretion removal and recruit collapsed lung segments. 
Immediately pnor to initiation the patient's ABC waspH 7.22. PCO; 72mrnHg. PaO: 91mmHg on 
an RO: of lOO*^. HFPV initial settings on the Volumetric Diffusive Respirator (VDR) were PIP 40. 
oscillatory PEEP of 1 lcmH;0. demand PEEPol 4cmH:(). respiratory rate 10. pulsatile frequencv 
of 400. 1:E 1.5:1. R02 100^, Within one hour of placement on Ihe VDR. copious amounts of thin 
milkv secretions were noted with suctioning. Twenty-four hours after HFPV placement. Ihe 
patient's ABC was pH 7.34. PCO; 57mmHg. PaO: 93mmHg on an FID; of 70'/. , Over the next 1 1 
days, the pulmonary abscess and necrotizing pneumonia resolved, On ICU day thirty, the patient 
was successfully placed back on AC. RR 10. V, 750. PEEP 7. and FIO; 509^ .'The p'atient was 
v\ caned to a 40^ trach collar and remained in the ICU for 1 1 more days. He was transfeired to the 
general care area and FI02 weaned to room air. Placement in a rehabilitation facility was obtained 
in days later. 

Discussion: To our knowledge there have been no smnlar cases reported in the literature. This case 
demonstrates the importance of having and ulili/iiig imilliplc options tor a patient's ventilatory 
requirements We believe that due to the extent ol the injuries reported neither HFOV nor HFPV 

alone would have provided the patient with a posmv 


A Ventilator Protocol for Fulminating Non-Cardiogenic Pulmonary Kdema 

JohnH. HoynlnnJr, RRT. Kenneth Hawkins RRT. Dean Holliind. RRT. Jasnn 
Hij:gins. RRT. Grant O'Keele MI) MPH. Parkland Health aiul Hospital System and 
UTSWMC. Dallas. Texas 

Background: l-or the puqM)sc ol our prottH;ol. Ihe setting and stabili/aiion of \i?nii!at- 
inj: end pressure during the initial seventy-two hours post injurs is fundumejilal, Tlie 
system end pressure is set and maintained at 2emH:() above the lower inlleelion |>t)iril 
as identitled on a static pressure-volume curve. Our proliKol is intended to decrease 
mortality in this high-risk patient population Methods: Tlic Oxygenation Index (Ol)' 
ol ten ventilated surgical/trauma ICL' patients ichosen in successumi thai present with 
fulminating iion-cardiogcnic pulmonary edema will he compared with Ol value (47i 
which has been assiKialed with KKK/t mortality m ARDS.' The padenis evaluated are 
as lollows: two patients each wiih 93'^ total body surface ;u-ea iTBSA) bunts, one gas- 
tiic b\ pass, one hip replaeemcnl. and m.x w ith pulmonary contusions. All patients were 
111 the initial jihase ol lluid resuscitation or were immediatelv p«.)si-op. Cardiac origin 
ol the edema v^as niled out in each case via ECG"s. Swan-(ian/ readings, and clinical 
presentation. Results: All patients bad Ols >47, Palicnl Ol's at protivol initiation 
ranged from 5()-'^>3. Ol the ten patients studied, eight patients suivived. one patient 
(pulmonary contusion) died, and one patient was not included in the final evaluation 
sccoiulary to a breach in pmlocol F-xperience: In the prtK'ess of refining our 
appioach, we discnvcied ihrce aspects ol iiianagement. which were especially imptir- 
tant. First, paltcnls nuist not develop respiratory efforts for tlie initial 24-72 hours p<ist 
onset. Our team used paralytic agents lo prevent patient respiiatorv eltort. Second, 
frothy secretions must be removed without compromising system end pressure. We 
used short hursts i !()-4()sec,) of 02 in the range of 25-liters/tninute through an in-line 
suction catheter advanced to tracheal level to displace frothy secretions. Third, end 
pa'ssure should not be compromised during ventilator disconnects. We successfully 
maintained end pressure during disconnects by cross clamping the HTT with padded 
hemostals. Conclusions: We usedOl as a marker in our evaluation because no other 
commonly used index for oxygenation incorporates the imp<irtance ot ventilating pres- 
sures. Fort et al' as.socialed Ols greater than 47 with MM)' , mnrlalily. .Mthough Forts 
work was done in a broader population, we believe that 01 prov ides an appropriate 
index for severity of illness in our population. Our initial experience w iih this protcKol 
suggests a decrease in mortality. Our findings dunng this evaluation are consistent 
with concepts presented in Amalo's- work in electncal impedance tomography. We 
recogni/e that this is a limited look at a complicated problem and much more work 
remains. We w ill continue to gather data as it becomes available, howev er, the small 
number of patients thai are included each year make a single center study difficult. A 
multi-center study of prospective patients may be the best approach. 

1 , Higli-lrequencv oscillatory ventilation for adult respiratory distress syndrome-A 
pilot study Crit Care Med 1997; 25: 937-947 

2. Regional pressure volume eunes by electrical iinjiedance toinography in a mtxJel of 
acute lung injuiy. Cril Care Med. 2(X)0 Jan: 28( I ): 178-83. 



De an Holland RRT Boh hsicltcr RRT, Jason Higgins BS RRT. Ken Hawkins BS RRT 
Parkland Health and Hospital System. Dallas. Texas, Depiirlment of Respiratory Care 
Introduction High frequency percussive ventilation (HFPV) has been shown to decrease 
mortality and improve oxygenation in the adult ptipulation by integrating bulk gas move- 
ment (tidal voluinc) with high frequency pulses. However, optimizing ventilator settings 
from initiation through weaning can be challenging even for the cxpcncnced clinician 
We hypothesize that opening pressures can be identified bs monilonng changes in proxi- 
mal pressure (DP) inside the phasitron (sliding venluri). Methods A multiple balloon lung 
model was attached to a Volumetnc Diffusive Respirator (VDR I by means of a #8 ID. 
ETT. The lung mtxJel w as submerged in a fifty-giillon aquanum and fixed at two different 
levels. A slow-flow (four 1pm) pressure- volume curve was pcrloniied at each deptli. 
Lower inflection points (LIP I were identified at cmH:0:ind 21,4 cniH^O with a sta- 
tistical software program ( STATA ). For the pur]xise of this work weassLxialed the values 
obt;uned forLIP's as representiitive of opening pressures. Tlie VDR was set withexpira- 
torv time to max ( infinity ). oscillatory PEFP of S cm H:(). pulse frequency 4(X). and i/e of 
9 (set on the dial). These settings were held constant throughout data collection. Total 
PHFP(TP) was defined as the sum of the oscillator* and demand PEEP level. For each 
group the demand PEEP was initiated at ()cinH:Oaikl incicascd in inca'inentsof 3 
cmH:0 until the total pressure exceeded LIP Data was collected at each level of demand 
PEEP for both groups, Measuiemenls were capluicd using a dillcrential pressure trans- 
ducer connected to tlie proximal sampling [Xirt of the phasitRm and interfaced through a 
space lab monitor (mtxJel 90603AI- DP was defined as the differcnce between the peak 
;md trough of oscillations. 

Figure 1 

> LIP 125cmH20 • U>214Gn«20 

RmiiIu In 
biitiT (troups 
ihc miximum 
W occurred 
when Ok TP 
wa& i;loboiit TO 
(he I IP (sec 
figufc I). 

Tout PFF.P IcalUO) 

Discussion Tins work suggests that 1 .IP can be- deteniiined by measuring pa'ssuiv 
chiiiiges inside tlie phasitron and proximal to the I: IT. We believe that these a'sulls repre- 
sent an initial step toward undeiManding the complex aspects of gas mov ement w iiliin the 
phasitron during HFPV. Further, application ciirly in a patient's acute pliase will deca-ase 
the potential for VILI secondary to cyclic tidal o[X'ning and closing ol alv eoli. We a'cog- 
nize additional investigation isnc*eded looptimi/c HI P\ settings in the clinical setting. 
We believe that future investigations should Uvuson ol quaniilving the a'sponseof the 
phasitmn (sliding venluri) to mech;mical factors within the lung. OF-02-175 

UME EXCURSION? DanaASiinon!.onBA . John R Holchkiss MD. 
Alexander B Adams RRT. Sung Chul Litn MD. John J Marini MD. 
David J Dries MD. Regions Hospital — HealthPartners. Universit> of 
WIN. St. Paul. MN. Background: To avoid ventilator associated lung 
injury (VALI), plateau pressure should be maintained < 32 cmH20. 
Other workers report that lung volume excursion, or the opening and 
closing of lungs during ventilation, may contribute to or cause VALI. .As 
the difference between plateau pressure and PEEP defines volume excur- 
sion, elevating PEEP reduces excursion and max protect against V.ALI. 
Methods: Anesthetized pigs vveie placed on PCV. f=2l)/min. I:E=I:2 for 
stx hours at Pset/PEEP settings of 20/3 (control). 35/15 (high pressure, 
low excursion), or 35/3 (high pressure, high excursion). ABGs. and pul- 
inonary mechanics were continuously monitored. At study completion, 
wet weight/dry weight ratios (WW/DW) were determined. Results: 
Pa02 and VT decreased with PCV = 35/3 but remained relatively 
unchanged for both 20/3 and 35/15. Edema, as measured by WW/DW. 
was increased with PCV of 35/3. Lung volume excursion or mean VT 
was greater for the PCV=35/3 group. The indicators of lung itijurx 

APa02. AVT) 

w ith a differ- 
ence in VT. not a difference in Ppeak. Conclusions: This repon of 
preliminarx' data from a study of VALI finds the effect of increased 
excursions of pressure or volume to be important. Along with the 
elevated plateau presstire in the induction of lung injury, increased PEEP 
may decrease lung volume (and pressure) excursion and protect the lungs 
from VALI. AHA SDG yy30IS4N: NIH SCOR 50152 


PCV VT(rnl/kg) 




2()/.'t|n=2l .10.9 




35/15 (n=:i 26 3 




.35/3 (n=3) 51.6 





Respirators Care • September 2002 Vol 47 No 9 

Tui;snAY. OrTonnR S, 1:30-3:25 PM (Rooms 20-21 


Dana A .SimoiiMm BA . John R Holchkiss MD. Alc\aiulci H Aikmi-. 
RRT. Jiilin Manni MD. Dasiil J Dries MD. Rciiions llospilal llcallli- 
Parlners. I'nn . ol MN. Si. Paul. MN. 

Backsniund: .\\ 1 .3 and d days allci cnrollnienl. the .ARDSnci studs 
rcporlL-d similar Pa02 \alues in patients recelvlnj; fi nilAji and 12 
iiiL/kg tidal volume yet mortality rates were 25'i dilleient between the 
two groups. While Pa02 or Pa02/F102 are used to determine lung 
injury status, these indiees may not faithfully traek the development or 
progressiim of ventilator induced lung injurs (VII. I ). We examined 
Pa02 during as VILl developed in svsine ventilated with a known inju- 
rious ventilatory pattern. Methods: Normal pigs were ventilaled at 
PCV = .^.V."?, I:F.= 1 :2. for 6 hours. Pulmonary mechanics and 
ABGs were continuously monitored. Post-study the lungs were 
extracted for wet weight/dry weight ( WW/DW) determination. Results: 
While Pa02 clearly decreased in 4 animals. Pa02 remained relatisely 
stable throughout the experiment in 4 animals (Figure). WW/DW ratio 

(displayed to the right of the 
Pa02 data I was elevated in all 
animals (normal=.^.?) 
indicating edema accumulation. 
Vt decreased after .^ hours of 
ventilation in all animals 
indicating a reduction in 
compliance Conclusions: 
Pa02 may not he a dependable 
index for the development of 
VILI. We speculate that 
hypoxic vasoconstriction can 
mask a progression of injury 
that could be tracked by a reduc- 
tion in compliance. AHA SDG 
99-W184N: NIH SCOR .SO 1.^2 


TlIK \ Al.l'K OK AN l■:^'Fl^iKN^■^ .SCOkK IN h;\ AI.l'A TIN(; 

C H.usMI.S. KKl . R IXvlK-n MS. KKI , M K.mklL- MI'A, KK I , I I .ilk RRT; I'l.oik RRT; 
1 Su.pp RK I . V .Sifsc-iiMm Rl< I ; A Aiiilaws .MS. RR I . C l,.iik- RR I . S Lmrencf RRT; L 

Y.nirifi RR I ; A RRT; K M^iivvk- RRI ; S Matk; S Ga.v MD 
RL-spir;i(.ir\ Care Depaniliciit. / 'tii\vi\il\ i>t Mithlynn Ht'dlth S\\rfm. Anil Arhin- Mit hliiiiii 

IN'I'RODl'C'TTON: A weakness ii)' many sdidics rvpinini: rciluecil dur.iti.>n .il \cnlilalion 
1 1 )( )V 1 IS ili.ii palii-nt se\ crity is .illcn mil e.tnsldcial in Itic c.impiirison. .Aitlmujili IX)V is 
le.lULCd. II ni;i\ Ix- ivIateJ l.> p.iliciil sL' an inipr.ncil syslcin, VS'lien sc\cnl\ - 
.uljusliiii: .1 prL-diek-il IX )\ iP IX )V| as .i tx-nchinalk In c.tniparc actual IX )V (,'\-l:)()Vl. it 
IS desirable ui use a picdiLlise iii.xicl which nialhcnialicully c.mlrols lor physiol.igic 
v.mablcs. Such a may Ix" iisclul asscssinji (he impact iil' process changes, such as a new We c.inveiled an adiill vcnlilator nKinaj^cmcnt perlomiancc impmvcmcnl (PI) 
Ic.ini in I9'H>. Follow inji \2 inontlis o( datac.illcclion. 6 months were gi\en loslandardi/c a 
wtMiiinii (across 6 ICl's) .uul l.i I.kus altcnii.iii .ill many taccis otllic \cnlil.ilioii 
process F^.illowmji an.ilhci 12 molllhs ol ilal.i colleclion. reduced limes wcreohsciAcd in 
iiuiin scemcnls ol llic U'lUllalioii process, iiickuliiit; IX)V PI niclhi^Js and pieliniin.iry 
results were pic\iousl\ te|-Mirlcii (Rcsp(\ire 2(M)1;4(>:[ 12'>i VVc w.inlcd to determine 
whelher iticditlcrenccs ohscrsc.l fielween (he (wo periods were due [oseven(y of pahent ill- 
ness or (oun improved elTicicncy, Our study t|ues(ion was "Are (he observed differences in 
pre vs pos( DOV a resuU ot padeiit '" METHODS: A-DOV was computed from 
data sheets completed by llie bedside RCP. F.illow Inc IRB appros al. P-rX)V was 
obl.imcd (he surgical ICU from an APACHE III dala-basc and (he tiles merged- We also 
calculated a vemilalory management elTiciency (Etl\ Ml ratio (Eftwi lA-DOV/P-tXJVl; the 
l.>wer[hc rati. 1. the bellcrltieeriiclency. Eorcompiirisons./xO.U.S (S(uden( /) was 
c.nsideied signillcani RK,SIT,TS: The (able shows median, mean, and SD values ol pre 
.iiid pos( iiiipleiuenlalion periods P-IX)V. A-DOV. and EtT\ m. Although there was no 
ditference between pre and ptist P-DOV or EtfvM- post A-CX3V was < pre .A-DOV and .A- 
DOV was < P-IX)V during both (XTiods. 

P-f X3V(dl A-DOV (dl EITvM pt) 




4 14 
4. 'J 

I 17 













PrevsPos( ;i* II2K3 0.012 

* companng mean Pre \s P. .si. tt coiiipanng P-IX)V \s A-DOV 

CONCLUSIONS: Tlic simiLii P IK )\ lor llie pre \s posl groups suggests patient similarity 
dunng bo(h study pericxis. and thai p.ilieiu phy suiiogy was n.i( (he primary rea.son tor (he 
.observed reduedon in A-DOV. AUhough (he elTiciency of \en(ila(ion (rended (oward 
improvement o\er (ime. A-DOV was sh.iner than (he P-DOV benchmark during (he pre- 
pen.xl a.s well, suggesting an efficient system (i> begin wi(h (A-DOV was only 72'^ of P- 
DOV in pre vs 62% in pos( peritxil. Such an evaiiia(u>n w ill be c.mducled ..n odier popula- Because the EffvM f^lio is adjusted for patient seventy i( may be useful in comparing 
patients w ithin and between institutions. OF-02- 161 


Robert S Campbell RRT FAARC . Bradlev R. Das is MD, Jav A. Johanmgman MD. 
Kenneth Das is Jr. .\1D. Sandra L. Miller MD. Chris Blakeman RRT. Richard D, Bran- 
son RRT F.A.ARC Unisers^ity of Cincinnati College of Medicine. Cincinnati. OH. 

BACKGROUND: The P-V curse may be used to determine optimal PEEP if a LIP is 
detected. Use of PV eunes are not yet standard practice due to inconsistencies in gener- 
ating ;ind in(erpreting the curse. We investigated the variability of LIP estimation (LIP- 
e) by six clinicians using visual inspec[ion of PV eunes generated using two different 
techniques. METHOD: Eight consecutive mechanically ventilated pts at risk tor ARDS 
ssere studied. Each pt seas placed on a Galileo Gold ventilator (Hamilton Medl which 
has a new automated PV maneuser(cons(an( pressure nselaspartof apre-climcal s.ift- 
ware package. Each p( w as chemically paralyzed for the prwedure and no pt had 
evidence of air leaks from chest tubes or ET tube. Automated PV curves (PV-A) were 
generated using a Pmax of 40 cmH20 and a pressure-rise of 2 emH20/see. Pressure, 
volume, and How svere measured at the proximal airway using the Galileo tlow 
transducer and data ssas recorded to a PC using available software package 
( Dalaloggerl. Static PV I PV-M I curs es svere also genera(ed on each p( using HK) ml 
aliquoLs from a calibra(ed synnge un(il airway pressure reached 40 emH20. Da(a ssas 
similarly eollec(ed to the PC during each static PV maneus er. A minimum of lour PV 
curses ssere obtained on each pt ((wo with each technique). PV curses svere printed and 
distributed ( in randomi/ed iwder) (o (hree in(ensivis(s and three respiratory care practi- 
tioners for esumation of LIP. The mean estimated LIP imd standard des iation ( SD i ss as 
determined and compared to a mathematically determined LIP (LIP-M= greatest com- 
pliance A). RESLTTS: Forty PV curves were' evaluated 1 20 PV-A. 20 PV-Mi. Mean 
LIP-e ranged from 7 (o 19 cniH20 tor (he eigh( p(s. Mean SD using PV-.A wa.s 2.3, with 
a max SD of 2.'> on pt 6. Mean SD using PV-M was 2.0. but SD exceeded 3.0 on pts .5. 
6. and 7. Max diff in LlPe from PV-.A svas S cmH20 for pt 6. Mean max cliff using PV- 
A was ,17 ± 1 .2 cmH20 .Vlax diff in LIP-e from PV-M ssas 1 1 cmll20 lor pt 6. Mean 
max ditT using PV-M ssas Is. 2 ±3.9. Maxdilfs using PV-M were usually due to one 
reviewer estimate. LIP-e with PV-,A was typically 1 -2 cmll20 higher than PV-M. Mean 
LIP-e of all reviessers ssas svithin 2.5 emH20 of the LIP-M on all but two cxcasions i -6 
on pt 2 and +4 on pt 4. both PV-M l. LIP-e ssas not identifiable on (svo .xcasion using 
PV-A and on fise occasions using PV-M. CONCLL'SIONS: LIP-e vanes widely 
be(ween clinicians. (lre'a(er sanadon ss i(h PV-A may rcslil( from having more data 
point-s (> 1 400 versus < 25) resulting in a "smtxnher" curse. De(emiinationof true LIP 
may beimprosed if PV isrcsiewedby multiple clinicians. Using PV curves to 
deteniline vent settings may he enhanced if an objectise methtxJ of inlerpre(a(ion were 
asailable. Clinical eftecliseness of setting PEEP at or abuse LIP on PV in terms of clini- 
cal outcomes. i:as exchange and lung mechanics requires turther ins estigation. 



Robert S- Campbell RRT FAARC , Bradle/ R Davis MD. Jay A Johannigman MD. 
Kenneth Davs Jr MD, Sandra L Miller MD, Richard D Branson RRT FAARC 
University of Cincinnati College of Medicine, Cincinnati, OH 
BACKGROUND: The pressure-volume (P-V) curve describes the mechanical 
properties of the respiratory system Current techniques for P-V curve measurement 
inclutje the supersyringe technique, multiple occlusion technique, and low-flow 
technique The Galileo Gold ventilator (Hamilton) incorporates an automated PV 
maneuver (pre-clinical software) thet uses a coistani pressure, which is adjustable 
between 2 and 5 cmH^O/sec We evaluated the accuracy and reproducibility of this 
au(oma(ed PV maneuve' m the laboratory METHOD- We designed a bench study to 
evaluate the accuracy and reproducibility of the automatec PV maneuver using the 
Galileo We also assessed Galileo's ability to deliver Ibe set pressure rise and any 
effect o( varying lung mechanics Five automated PV curves were performed on one 
side of a two-chamber test lung (TTL) for each of eight combinations of resistance (5 
and 20 cmHjO/Usec), compliance (20 and 50 ml/cmHzO), and pressure nse setting (2 
and 5 cmH20/sec) Pressure, volume, and flow delivery was measured at the prox 
aln*ay a( a sampling rate of 70/sec and recorded to a PC with commercially available 
monitonng package (Datalogger), from which, PV and Pressure-Time (PT) curves were 
generated The measured PT cun/e was plotted against a mathematically determined 
curve and any deviations were noted Peak and mean flowrate cunng each maneuver 
were also measured and recorded Three manual PV curves were performed at each 
combination of R and C using 100 ml aliquots from a 5 L calibration syringe 
Automated and manual PV curves were overlapped and any deviations noted 
RESULTS: Figure 1 reveals the overlapped automated and manual PV curves Figure 
2 reveais the PT curves plotted aga.nst the mathematically determined PT curve 
Pressure rise settirg of 5 cmH,0/sec at high C resulted in a mean flow > 14 L/min 
Mean flow at all other combinations was s 6 Umin The PT curve of the automated PV 
curve deviated from the malbematical curve (undershoot) m the first 8 seconds of the 
maneuver Reproducibility of the automated PV curve was excellent There was good 
correlation between the automated and manual PV curves CONCLUSIONS; The 
automated PV curve maneuver on the Galileo Gotd ventilator yields reproducible and 
accurate measurement of lung mechanics Bersefits associated with use of an 
automa:ed PV measurement include elimination of interoperator variability, faster 
completion of the maneuver, and avoidance of oatient-ventitator disconnection. Clinical 
evaluation of the automated PV maneuver appears warranted 

I tt^rt c\trtU 

OF-02- 172 



Open Forum Author Index 

Boldface type indicates presenters. 


Chatburn. Robert 1. 


Abmas, F.rika 


Clark. Calvin 


Accxedo. Russell 

107.") (2) 

("lark, Steven 


Acker, R 


Clark, Terri 


Acton, James D 


Cleary, J 


Adam, Susan 


Clink, Jamie 


Adams, Alexander B 


Cohn. Robert C 


Ahearn. G 


Conlin, Tim 


Alfaro, Mary Pal 


Conway, Edward 


Alvarez, .^nita 


Cormican. Richard 


Ancy, John J 


Cornelissen, P 


Andrews, Allan 


Coulter. Terrence 


Ari, Arzu 


Cox, Timothy 


Asselin, Jeanette 


Craig, Damian 


Atherton. Harry 


Cravener, Donna 


Atlw ood. Jeffrey A 


Cullen. Deborah 


A/ciza, Elana 



Cullen, Edward 


Bagwell, S 


Dabbagh, Osauma 


Baker. Randal 


Dal Nogare, Anthony 


Baldesare-Burton, Karen 


Dalai, Bhavin 


Banzon, J 


Dalai, Prana\ 


Burnett, Mary 


Danek, Peggy 


Bast. Paul R 


Davies, J 


Bates, Sara-Lou 


Davis. Bradley R 


Batt, S 


Davis, K 


Batts, Brenda K 


Davis, Kenneth Jr 

1093 (2) 

Bauer. K 


Davo, Salvador A 


Beck. George 


De La Garza. Jennifer 


Benschoter, A 


Deakins, Kathleen 


Benzaquen, Barbara 


Dechert, Ronald 


Bergqiiist. Theresa 


Dekeon, Mary 


Berkenbosch, John W 

1033 (2),1047,1062 

Delacruz, Austin E Jr 


Biggs, Alan 


Denials. Bradley 


Blackson. Thomas 


Dickson, John 


Blaes, Chris 


DiFiore, Julie 


Blakeman, Chris 


Donlin, Mary E 


Bonn. Karen 


Dougherty, William 


Bonnell. Bruce 


Doyle, Cathy C 


Boynton. Jackie 


Dries, David 

1062 (2),1092. 1093 

Boynton, John H Jr 


Duncan, Cheri A 


Branson, Richard D 


Durning. Suzanne M 


Broccard, Alain 


Dm an, Joe 


Brown, Melissa K 


Dwyer, Joseph G 


Brunst. Gail 


Bucher. William 

. KW4 


Buehler, C 


Eckbold, Laurene 


Burks, Dawn 


Ldens, Jerry 


Burns, Edward C 


Edgar. Marlene A 
Elliot, Deborah 



Estetter, Bob 

1046,1047,1076 (2).I088.1092 

Caldcron. RacqucI M 


Campbell, Robert S 



Cappadoro, Carla 


Fallon, Kevin 


Cappon. J 


l-arrell, Tracey 


Chang, David VV 


lascia, Wendy 





Fedor, Kalhcrine L 


Mess, Dean R 

FciiL-hl. Hric 


Heulitt, Mark J 

Kink, James B 


Hiasa, Yuki 

Hlemini!. Robert 

1 067 

Hiatt, Larisa M 

Flood. Torn 


Hickcy . Melanie 

Folk. L 


Higgins, Ja.son 

Francis, Anne 


Hildenbrand, Amy 

Frazier. Zack 


Holland, Dean 

French, William 


Holt, Shirley J 

Frj myer, Tim 


lloogebooni. James 

Fu, Gang 


Hospodar, Gary J 

Furnian. Ciilberl 


Holchkiss. Jiihn R 
Hon. Yangyi 


Huong. Le Thi Thu 

Galindo, Arcenio 


Hurst. Victor IV 

Gardenshire, Doug 

1038,1041 (2) 

Hyte, Beverly 

Ciardner, Sally 


Garrison, Michael 




Idicula, Idichandi 

Gentile. Michael 


George. Ann 


Giudici, Nicole 


Jackvony. Rebecca 

Glynn, Brian 


Johannigman. Jay A 

Godinez. Rodolfo 


Joplin. Kelly 

Goeting. Ral'aello 


Josephson. Christina 

Goldstein, Mitchell 


Joyner. Robert L 

Gomez, Ann 


Goodfellow. Lynda Thomas 


Goplani. Kamal 


Kacmarek. Robert M 

Goshima, Himki 


Kallstrom, Thomas J 

Grab. Eli/abelh 


Kane. Thomas M 

Graff. Gavin R 


Keenan, Jim 

Granton. John T 


Keeney. Susan 

Gray. Craig 


Kemp, Sharon 

Greenspan, Jay S 


Kercsmar. Carolyn 

Grgas. Sandra 


Kesten, S 

Groller. Joseph 

1061 (2) 

Kester, Lucy 

Grueber, Ryan E 


Kihara. Norio 

Guess. Terrell M 


King. Patricia 

Gutierrez, Charles J 


Kingsley, Kimberly M 
Kirsch, Jeni R 


Kissin, David 

Haas. Carl 


Kobayasi. Nobunori 

Haines. Fred 


Kobets, TV 

Hales, Roberta \. 


Koehl. Deborah 

Haley. Eileen 


Kohlman. Joseph 

Hall. Renee A 


Konkle. M 

Haniby. Kevin 


Konstan, Michael W 

Hardie. William D 


Kunig A 

Harrison, Fedrual 


Kurokawa, N 

Harrison, Julie 


Harrovs , JetYrey 


Hartling, Chris 


Lambert. Sally 

Hastings. Dennis 


Lamberti, James 

Hawkins. Kenneth 


Lamparyk, .Andrew 

Hawkins. Rachel 


Lan, Ia' Thi Tiiyet 

Helmhol/. H Jr 


Lane. C 

Hernandez. Grace 


Langenderfer. Bob 

Hertzog. James H 


Lawas-Alejo. Perpetua 


1038.1063 (2),I0S() 






1046, 1047, lOSX, 1092 (3) 




1062 (2), 1092, 1 093 





1076 (2) 



1034 (2). 1066 
1043.1054 (2),I066 




Open Forum Author Index 

Lawrence. S 


LeGrand, Terry S 


Nadkarni. Vinay 

Lekili's, Koin 


Nagel. Mark W 

Leonard. M 


Napoli. Linda A 

Lcshko, Robert 


Neary. Mary Ann 

Lewis. Jeff 


Nelson. Catherine 

Lewis. Nathan 


Nesbitt. Jeff 

Lim. Sung Chul 


Newman. V 



Nunez. Gabriella 

Lucrezia. Joseph 


Lugo. Ralph A 


Lv. Dongxing 


O'Brien. Jackie 
Ochikubo. Clark 


Oestreich. Trenton 

Maclntyre. N 


Ogrinc, Susan R 

Mack. S 


Ohmura. Akito 

Madsen. Ed 


OKeefe. Grant 

Malinowski. Tom 


Oldenburg. Gary G 

Mallo) . Raymond 


Opdahl. G 

Maloney. Beverly 


Op't Holt. Timothy B 

Mann. Lawrence 


Orens. Douglas K 

Mansaro. Lisa 


Orscheln. Karl J 

Mansouri. Sohrab 


Overton. Melissa 

Marecle. K 


Marini. John J 

1062 (2). 1092. 1093 

Marion. K 


Padgett. Doug 

Martin. Gilbert 


Paluck, Sally 

Martin, James E 


Parmar. Rasik 

Martino. Rosemary 


Pasquale. Michael 

Mashek. Joel 


Patzwahl, Leslie 

Masini, Douglas E 


Paid. Da\ id 

McArthur, Charles 


Pavlakovich, David 

McBain. Stacy M 


Pearson. Deb 

McCall. .Athena 


Penfil. Scott 

McCarthy. K 


Pernia. M Luchia 

McCrory. James 


Peters, Cindy 

McKibben. Andrew W 


Peters. Jay 1 

Meilor. Sean 


Pctlinichi. Scott 

Menees. Katherine L 


Picchi, Perry 

Menjoge. S 


Pikarsky, Robert S 

Meyer, Kurt 


Ple\ ak. D 

Millard. Mark 


Poulima. Prayoun 

Miller. Frank 


Prater, Misty 

Miller. Kenneth 

1049.1061 (2) 

Price, Terri 

Miller. Kent 


Prieur. Barbara 

Miller. Russell K 


Pruitt. Christa 

Miller. Sandra L 


Pullano. Thomas 

Mitchell, .Jolyon P 


Pyne. Steven 

Miyagawa, Tetsuo 


Miyaji. Tetsuya 


Monahan. John 


Quicho. Louisa 

Moorhead. Jeanine 


Mottram, Carl I) 


Muller. Susan .\1 


Raake, Jenni L 

Munski. JoAnn 


Ramirez. Ann 

Mussetter, r)a\ id 


Rao. Ra\ indra 

Myers, Timothy R 

Rau. Joseph L 


Rebel, ,Iim 










1075 (2) 









Respiratory Care • September 2002 Vol 47 No 9 

Open Forum Au i hok Indkx 

Rcndlc. John 
Restri'pci, Kuben D 
Rice. Richard D 
Riciulcaii. Ariiumd D 
Riley, Charles 
Robinson, Chay 
Rogncss, Robert ,1 
Rohrer. Martin 
Roman, Charles 
Romig, Donald 
Rose, Mark 
RulT. Jeanne E 
Rutherford, Eric 
Rutherford, Mary 
R\an. Deb 
Rye, Kathy Jones-Bogg.s 

,Sabato. Katie 
.Saldaiia, Jerry 

.Salim, AH 
Sa\age, Jill 
Scanlon, Paul D 
Schneider, Sidney R 
Schoettker, Pamela 
Schuler, Cheri 
.Schumacher. D 
Schwartz, Andrew R 
Seislove, Elizabeth 
Selhorst. Dawn 
Sha, Muneyasu 
Shaffer, Thomas H 
Shelledy, David C 
Shimer, Richard 
.Sikkema. Jennifer 
Simonson, Dana A 
Simpson, Pippa 
Sindel, Bruce 
Sittig, Steve 
Slaughter, Steven 
Smith, Brian 
Smith, Laura D 
Smith, Todd 
Sob/ak, Ste\en 
Sorenson, Helen M 
Stapp, L 

Stevenson, Valerie 
Stoller, James K 
Sturtz, Wendy S 
Subramanian, Sreekumar 
Surti, Shahid 
Swift, Dave 

Tan, Hemg Lee 
Tearl, Donna K 
Terhune, Chuck 


Thomas, Scott 

10.^2,10.^8.1041 (2) 

Thurnian. Tracy L 


I'iep, Brian 


Tinion, Charlotte 


Tinaglia, .A 


Tobias, Joseph D 


Touch. Suzanne M 


Tracy, Michael 


Treat. Richard 


Trevino, Michael 


Trottier, Steven 


Turck. Kate 




Urnietz, Kathy 


Van Hooser, Theron 


Van Scoder, Linda 


van Stralen, Daved 


Vasilenko, YY 


Villareal, D 


Vines, David L 


Volsko, Teresa A 




Waggoner. Susan K 


Wallace, Wayne 


Walston, Cathy C 


W ang, Vujing 


Wankum, Patricia C 


Ward. J 


Weinbaum, Frederick 


Weinstein, Gary L 


Weis. Kerry 

1062 (2), 1092,1093 

White, K 


Whitford, Gail 


Whitman. Robert 


Wiersgalla, Susan 


Williams. Joy Jurena 


Williams, Loretta 


Witzke, Scot M 


Wood. Brian 


Wu, Jimmy 



1087, 1093 

Xu. Jing 




Yang. Linda 


Yetsko, Dennis 


^'oung. L 


Zhang, Yong Yu 


Zodercr. Heather 





1038.1063 (2), 1 080 









1080 (2) 

1042,1033. 1078(2) 


1053 (3) 



1038.1063 (2),1080 





Respiratory Care • September 2002 Vol 47 No 9 


Congress Exhibitors 


at the 48th International Respiiatory Congiess 
of the .\merican Association for Respiratory Care 

October 5-8, 2002 
Tampa, Florida 

Thousands ot examples of respiratory care equipment and supplies are displayed, discussed, 

and demonstrated in tfie exhibit booths at the International Respiratory Congress. 

The AARC thanks the firms that support the Association by participating. 

(Exhibitors confirmed by August 2 

Exhibit Hours 

Saturday, October ."i 
Sunday, October 6 
Monday. October 7 

2002 are listed. 

1 1 AM to 4 P.M 
1 1 AM to 4 PM 
1 1 AM to 4 PM 


Ackrad Laboratories 

Advance Newsmagazines 

Advanced Respiratory 

AeroGcn. Inc. 

AG Industries 

AIRE Institute 

AirSep Corporation 

Allegiance. A Cardinal Health Co. 

Allergy & Asthma Network. Mothers of Asthm 

Allied Healthcare Products Inc. 

Alpha- 1 Foundation 

Ambu, Inc 

American Academy of Allergy, Asthma and Im 

American Mobile Healthcare 

American Sleep Apnea Association 

Amvex Corporation 

Anew International 

ARC Medical, Inc. 

Arizona Hospital & Healthcare Assoc. 

Armstrong Medical Industries Inc. 


Axcan Scandipharm 






B&B Medical Technologies 



Barnes-Jewish Hospital 



Bay Corporation 



Bayer Diagnostics 

Island 322 


Bedfont Scientific USA 



Beevers Manufacturing and Supply 



Beta Biomed Services. Inc. 


Island 914 

Bio-logic Systems Corp 


atics 134.S 

Bio-Med Devices Inc. 



Board of Registered Polysomnographic 

Technologists 847 


BOC Gases 



Boehringer Ingelheiin Pharmaceuticals 

Island 334 

niunology 443 

Borgess Health .Alliance 



Bunnell Incorporated 






Cadwell Laboratories, Inc. 



California College for Health Sciences 





Island 722 


Carilion Health S>stem 
Carolinas Healthcare System 



I T21 

Centers for Medicare & Medicaid Services 
CH.AD Therapeutics. Inc. 



Ri-spiRATnR>- Care • Septf.mbfr 2002 Vol 47 No 9 


Congress Exhibitors 





Children's Heahhcare of Ailaiua 1310 

Children's Hospital 74>S 

Children's Hospital San Diego 1 224 

Children's Mere) Hospitals & Clinics 747 

Chiron Corporation 1 132 

Clear Hl.D 13().S 

Committee i)n Aeereditation for Respiratory Care 1 24(i 

CompHealth 54 1 

Compumedies Limiled 540 
COSMED S.R.L. 228-230 

Cross Country TravCorps 1 239 


Dale Medical 
Datex-Ohmeda. Inc. 
Del Mar Medical Systems 
DeVilbiss/Sunrise Medical 
DEY. L.P. 
DHD Healthcare 
Draaer Medical, Inc. 




Island no 



Island 400 

Hudson RCl 
Hy-Tape International 

Impact Instrumentation. Inc. 
IngMar Medical. Ltd. 
INO Therapeutics. Inc. 
Instrumentation Industries, Inc 
Instrumentation Laboratory 
Integris Health 
Invacare Coiporation 

J.H. Emerson Company 



Kimberly-Clark Ballard Medical 
Kindred Hospitals Tampa Bay 
King Systems Corporation 



Island 1026 

Island 1108 


sland 1114 




EME Medical Island 1022 

Ferraris CardioRespiratory Island 1000 

Fisher & Paykel Healthcare. Inc. Island 200 

Florida Hospital 544 

Flotec Inc. 923 

Forest Pharmaceuticals, Inc. Island 1 208 

Foundation Enterprises 647 

Freedom Medical. Inc. 343 

Fuluremed America, Inc. 944 

Galemed Corporation 1 24 1 

GE Medical Systems Information Island 307 

General Biomedical Services Inc. 227 

Georgetown University Hospital 538 

GlaxoSmithKline Island 310 

Goldstein & Associates/Neonatal Intensive Care 1033 

Grass-Telefactor, An Astro-Med, Inc. Product Group 1404 


H. Lee Moffitt Cancer Center & Research Inst. 447 

Hamilton Medical. Inc. Island 210 

Hans Rudolph. Inc. 1128-1130 

Hans Rudolph. Inc. 1146 

Healthline Medical 240 

Heart Hugger/General Cardiac Tech 534 

Hill-Rom Co Inc. 1411 

Hi-Tech Hoses 1 1 39 

Hospitak by Maersk Medical Inc. 940 

Lambda Beta Society 
Lippincott Williams & Wilkins 



Marsh Affinity Group Services-Seabury & Smith 745 

Masimo Corporation Island 1120 

Maxtec. Inc. 836 

Medcare Diagnostics, A Division of AirSep Corporation. 1403 



Island 422 

Island 1008 

Island 1032 









Island 434 






Medical Center of Central Georgia 

Medical Graphics Corporation 


MediServe Information Systems 

Medline Industries Inc. 

MedStaff, Inc. 

Merck US Human Health 

Mercury Medical 

MES. Inc. 


Michigan Instruments 

Micro Direct, Inc. 

Monaghan Medical Corporation 

Mosby-W.B. Saunders Co. 

MPL Professional Health Educators 

MSA Instrument Division 

MSI Healthcare 

National Board for Respiratory Care 
National Emphysema/COPD Association 
ndd Medical Technologies 


Respiratory Care • September 2002 Vol 47 No 9 


Congress ExiimnuRS 


Nelicor Puritan Bennett 

Neotech Products. Inc. 

Nephron Pliiirniaceulicals 

New Hano\ci- Health Network 

Newport Medical Instrumeiils 

Nihon Kohden America Inc. 

Nonin Medical. Inc. 

No\a Biomedical 

Novant Health/Forsyth Medical Center 

Novartis Pharmaceuticals Corporation 



Ohmeda Medical 

Olympic Medical Corporation 

Omron Healthcare 

Orlando Regional Healthcare .System 

Oxford Instruments Medical. Inc. 


PARI Respiratory Equipment Inc. 

Passy-Muir. Inc. 

Pegasus Research Corp. 

Percussionaire Corp. 

Philips Medical Systems 

Porle.\. Inc. 

Praxair Inc. 

Precision Medical. Inc. 

Primary Children's Medical Center 

Pulmonetic Systems. Inc. 

Puritan Medical Products, Inc. 

Radiometer America Inc. 



Roche Diagnostics Corporation 

Ross Products Di\'ision ,^bbott Laboratories 

RT Magazine 

RT Temps/RT Career Education 



Island 800 

Stellate Systems 




1 141 



Tech Group Inc 

Tech Net Medical LLC 

Tele Diagnostic Systems 



Teledyne Electronic Technologies 
TF&G Products - The Fmger Guard 




Thayer Medical Corporation 
Tiara Medical Systems. Inc 

TSI Inc. 

Island 2 I.S 




US COPD Coalition 


U.T.M.D. Anderson Cancer Center 
Ilniversitv Health Svstpms of Faster 







Island 1214 




Island 2.M 



Island 120 

Island 614 

Island 1014 




University of Arkansas for Medical Sciences 
University of Maniand Medical System 
University of Virginia Health System 

Vapotherm. Inc. 

Versamed Inc. 

VIASYS Healthcare 

Vital Signs. Inc 


Vortran Medical Technolosv 1. Inc. 


Wellstar Health System 
Western Medica 
Westmed. Inc. 

Zoll Medical Corp 







Island 1220 


Island 500 

Island 622 







Salter Labs 

Schiller America. Inc. 

SDl Diagnostics. Inc. 

Sechrist Industries. Inc. 

Scnsidyne. Inc. 


Shands Hospital 

Siemens Medical Solutions 

Sleep Cor 

SleepNel Corporation 

Smooth-Bor Plastics 

South Carolina Hospital A.ssociation 






Island 222 


Island 1228 






Ri-spiRATOR'*- Care • September 2002 Vol 47 No 9 


Respiratory Therapist 

Relocate to the Beautiful Colorado 
Rockies! Penrose-St. Francis 
Health Services, one of the 
nation's Top 100 Hospitals, has 
openings for Respiratory 

Colorado Springs offers breathtak- 
ing scenery, a mild, dry climate, 
endless recreational opportunities, 
great schools, affordable housing 
and cultural diversity. 1-2 years 
experience required. NBRC certifi- 
cation/registration as a respiratory 
therapist with 2 years in trauma/ 
adult critical care. Prefer 
intubation experience but willing 
to train. 

Colorado license required. 
Positions are available at Penrose 
Main, Penrose Community & St. 
Francis Sleep Lab. To apply, please 
email your resume to recruitment 
©Centura. org, fax 719-776-2489 
or apply online at 

Lander Valley Medical Center 


Riverton Memorial Hospital 


Come home to Wyoming's lofty mountains, clear lakes, natural beauty & year-round 
recreation. Central Wyoming Healthcare Network includes two JCAHO facilities: 
Lander Valley Medical Center and Riverton Memorial Hospital. 
Websites: or 

Lander was rated the 5th Best Small Town in America & one of the "coolest moun- 
tain towns" by a national publication, Riverton is a modern business community and 
a regional leader in technology education. Visit or 

Respiratory Therapy duties include routine and critical care inpatients and some home 
care. Riverton hospital has an opening for an RRT or CRT with Polysomnographer 
training for our Sleep Lab. All positions require CRT or RRT, plus valid driver's license 
and clean Motor Vehicle Record. 

• $2,000 Sign-On Bonus 

• Relocation Assistance 

• Insurance & Paid Time Off Benefits 

• NO State Income Tax, Traffic, or Crowds 

Submit resume to Human Resources, 2100 W. Sunset, Riverton, WY 82501, Riverton phone (307) 856-3465, 
fax (307) 857-3586; or phone (307) 335-6580, fax (307) 335-6237. 

Circle 1 29 on product information card 

Circle 1 25 on product information card 

Staff Therapist 

Cuine join us on heautitul WhiJhey Island, located two 
hours north of Seattle, WA. Whidhey General Hospital 

is a 51-hed public district hospital, owned and operated 
by the residents of Whidhey Island. The hospital is fully 
accredited hy the Joint Commission on Accreditation ot 
. Healthcare Organirations and is an all licensed facility. 

We are currently seeking a Respiratory Therapist 

with at least one year hospital experience 

and WA licensure. RRT is preferred. We offer 

a competitive salary and benefits package. 

Experience life on Whidhey Island. Our small 

community is benefiting from the most 

advanced technology and skilled 

professionals. Together we are making a 

difference in a place where life is different. 

Apply tii: 

Whidhey General Hospital 

P.O. Box 400 

Coupeville, WA 98239 


(360) 678-7661 - Fax 

Or apply online @ 

www. wh idheygen.or^ 

General Hospital 


As one ut the Midwcsc's leading htahh i.are systems, Ministry Healtli Cjte [eanu caring protessionaU with 
leading-edge technology to bring a full continuum of high quality care and services to nonh and central Wisconsin and 
eastern Minnesota. If you wane to put your career on the fast track in a System where caring makes the conneaion, v 
invite you to consider the following opportunity at Saint Joseph's Hospital in Marshfield, Wisconsin: 

Respiratory Therapist 

Flill or Part - Time. A.s a Reipiratur) Ihtrapisi with us. vuu II ha\c ihu upporeimiiy to enhance your clinical expertise- 
in providing a diverse range of services through: 

• Rotation through Surgical. Medical Pediatric, and Neonatal ICU's 

• Participating as a member of the Neonatal Transport Team 

• Performing pulmonary rehab, smoking cessation and general respiratory procedures 
" Delivering specialt)' gas therapy {Nitric Oxide & Heiiox) 

• Working with a wide variet\' of adult, neonatal and pediatric ventilators including high frequency ventilators 

To he considered, you must be a graduate of an approved Respiratory Therapy Program and possess current WI licensi 
Hr-'i^tr h' \\y.- \ uinn,)! Bturd for Respirator)' Carc as well as clinical experience in aU areas of respiratory care is prcfetrcd. 

Saint Joseph s Hospit.\l 

offers a compt'titivc salary and attractive benefits including health, dental and lite 
insurance, retirenienl plan. t.ix sheltered annuities, on-site child care and ill child day care, and more. For consideration, 
please call, send ore-mail your resume, to: HR.-Usociatc, Saint Joseph s Hospit;il. 61 1 Saint Joseph Avenue. Marshfield. 
Wl 54449. (800) 221-37.V1. extension 77880; E-mail: sihjobs@stiosephs-marshficld.oig i ' 

JIL Saint Joseph's Hospital 
TIT Ministry Hhalth Care 


Where caring makes the connection. 

Please visit our "Find a Job" pages on our website al: 

Circle 135 on product information card 

Circle 143 on product Information card 

Foote Health System, a 411-licensed- 
bed integrated health system, was 
recently ranked as Jackson, MI 
Employer of Choice. Find out what 
our 2,500 employees already know — 
Foote offers health care professionals 
a wide variety of care environments in 
which to learn. Located in Soutli 
Centra] Michigan, less than an hour 
from Detroit, .Vin Arbor ;ind Linsing, 
Jackson offers a small town commu- 
nity with access to the arts. 

Foote has a full-time RRT opening 
with a 12-hour night shift opportunity 
which incorporates night shift differ- 
ential and a night shift bonus. We 
have a flexible benefit program, on- 
site fitness facility, home-based sick 
child care program and much more. 

For immediate consideration please 

contact: Pat Stapish, Recruiter, 

Foote Hospital, 205 N. East Avenue, 

Jackson, MI 49201 

Email: patricia.stapish@\ 

Phone: 517-841-7994 

Fax: 517-789-5933 

Circle 151 on product information card 

Respiratory Therapist 

Austin Medical Center has been 
named one of the top 100 hospitals 
in the U.S. by HCIA-Saths, Em- 
ployer of the Year b\' the American 
Association for Medical Transcrip- 
tion and one of the Top 50 Teaching 
Hospitals in the U.S. Join our dedi 
cated team of Respiratory profes- 
sionals. Currently we hayean excel- 
lent full-time opportunity for a Res- 
piratory Therapist. Qualifications 
include graduation from a NBRC ap- 
proved Respiratory Care Program 
and Minnesota Respiratory Care 
Practitioner credentials. 

Austin Medical Center offers a com- 
prehensive and competitive salary 
and benefit package. For additional 
information contact Ken Slegh in the 
Human Resources Department: 
1000 First Dri\e N\V 
Austin, MN 55912 
Phone: 507-4.^4-1633 
Fax: 507-437-7824 




Equal Opportunity Employer 


I Austin Medical Center 

|:.,,„ .^ 

Circle 146 on product information card 

lisjii' for a My 0]i)oriiaity? 

Progressive, full-service hospital in beautiful Branson, Missouri is looking for 

full-time Registered/Certified Respiratory Therapists to be a part of a team 

that lives and breathes the FISH! philosophy! 

Successful candidates will be hooked on working with physicians 

to provide diagnostic/therapeutic procedures for patients with disorders 

of the cardiac, respiratory, neurologic, and vascular systems. 

Requirements include: 

• Graduation from an AMA-approved school of Respiratory Therapy 

• Registery eligible (pass boards within 1 year of employment) or 
Registered by the National Board of Respiratory Care 

• Current license to practice Respiratory Care in the state of Missouri 
and current BCLS certification 

• A minimum of one (1) year critical care experience is preferred. 

Competitive salary and benefits package available! 

Please send your resume to: 

Skaggs Community Health Center • PO Box 650 • Branson, MO 65616 

FAX: 417-335-7166 • email: 

For more information about 

Skaggs Community Health Center and life at the 

lakes in Branson, Missouri, 

visit us on-line 

(get it? "on-line"?) at! 

Circle 149 on product information card 

Visit our onl 

ine store at http://www 



where you can 

order all your respiratory 

educational and promotional items, inciud 


books, aud 

io cassettes, videota 



independent study p, 


and computer 


American Association for Respiratory Care 



An individuol lb eligible it he/ she lives m the U S oi its territories or was an Active Member 
prior lo moving outside its borders or territories, ond meets ONE of the following criteria ( 1 ) 
IS legally credenlioled os a respiratory core professional if employed rn a state that 
mondates such OR (2) is a groduote of an accredited educational progrom in respiratory 
core, OR (3| holds o credential issued by the NBRC 


Individuals who hold o position related to respiratory core but do not meet the requirements 
of Active Member shall be Associate Members They hove all the rights and benefits of the 
Association except to hold office, vote, or serve as chair of a standing committee The 
followinq subclasses of Associate Membership ore available Foreign, Physician, and 
IndustrioT (individuals whose primory occupation is directly or indirectly devoted to the 
monufoclure, sole, or distribution of respiratory core equipment or supplies). Special 
Members ore those not working in a respiratory core-related field 


Individuois will be classified os Student Members if tfiey meet all tfie requirements for 
Associate Membersfiip and ore enrolled in on educational program in respiratory core 
occredited by, or in tfie process of seeking accreditation from, on AARC-recognized agency 

SPECIAL NOTICE — Student Members do not receive Continuing Respiratory Core 
Educotion (CRCE) transcripts. Upon completion of your respiratory care education, 
continuing education credits moy be pursued upon your reclossificction to Active or 
Associate Member 

Please read the eligibility requirements for each of the classifications 
above, then complete the form. All information requested must be 
provided, except where indicated as optional. See other side for more 
information and fee schedule. Please sign and date application on reverse 
side and type or print clearly. Processing of application takes 
approximately 15 days. 

_ Active 

□ Foreign 

n Physician 

Ij Industrial 
□ Special 
D Student 

Last Name 

First Name 

Social Security No. 
Home Address 

Would you hke to receive our monthly newsletter, AARC Report, 
by email? 

Yes D No 

Have you ever been or ore you currently in the military? 
..: Yes ! i No 

Demographic Questions (optional) 

We request that you answer these questions in order to help us design 
services and programs to meet your needs. 

Primary Job Responsibility (check one only) 

^ Director (Technical or Program) ^. Therapist/Technician 

D Supervisor D Medical Director 

n Diagnostic Technologist ' Student 

n Instructor/Educator Staff Nurse 

□ Other, specify 

Type of Business 

L^ Educational Institution 
D Home Health Agency 
D Hospital/Acute Care 
D Other, specify 

Manufacturer or supplier 
Outpatient Clinic 
Physician office 
Skilled Nursing Facility 

Check the Highest Degree EornecJ 

D High School Bachelor's Degree 

D RC Graduate Technician ^ Master's Degree 

n Associate Degree D Doctorate Degree 

Number of Years in Respiratory Care 

D 0-2 years D 11-15 Years 

n 3-5 years D 16 years or more 

n 6-10 years 

Job Status 

D Full Time 

D Part Time 

City . 



Phone No. 

You are automatically assigned to a state society based on your home 
address. If you wish to be assigned to a different state society, please 
indicate which state that is here: 

Work Information: 

Place of Employment 



State Zip • 


n RRT 
n CRT 
n Physician 
n RN 

Dote of Birth 




n Perinotol/Pediatric 



School/RC Program 





Phone No. ( 1 

Preferred Fax No.( 


Phone No. ( I 

Expected Date of Graduation (required information) 

Preferred Email Address 
Preferred mailing address 



Month Year 

American Association 


Respiratory Care 

11030 Abies Lane 

Dallas, TX 75229-4593 • [972] 243-2272 • Fax [972] 484-2720 

American Association for Respiratory Care MEMBERSHiP APPLiCATiON 

Membership Fees 

Payment must accompany your application to the AARC. Fees are 
for 12 months. These fees contain the $12.50 new members 
processing fee. Renewing members (except students) con deduct 



Respiratory Care journal) 

u Active $102.50 

n Associate (Industrial or Physician) $102.50 

n Associate (Foreign) $117.50 

D Special $102,50 

D Student $ 50.00 


AARC CHOICE MEMBERSHIP(Choose one publication) 

D Active $ 91.00 

D Associate (Industrial or Physician) $ 91.00 

D Associate (Foreign) $106.00 

n Special $ 91.00 

I want D AARC Times D Respiratory Care journal 


AARC PLUS MEMBERSHIP (All publications and other items) 

u Active $137.50 

D Associate (Industrial or Physician) $137.50 

D Associate (Foreign) $177.50 

n Special $137.50- 

(Includes one free section - please mark choice below.) 

Specialty Sections (optional) 

Established to recognize the specialty areas of respiratory care, 
these sections publish a newsletter four times a year that focuses on 
issues of specific concern to that specialty. The sections also design 
the specialty programming at the national AARC meetings. 

n Adult Acute Care Section 

n Education Section 

n Perinatal-Pedictric Section 

D Diagnostics Section 

n Continuing Care- 
Rehabilitation Section 

n Management Section 

n Transport Section 

D Home Care Section 

D Subacute Care Section 

$15.00 1 








$15.00 1 


I hereby opply tor memberstiip in the American Associolion for Respiratory Core 
and have enclosed my dues If approved for membership in the AARC, I will 
obide by its bylows and professional code of ethics I outhorize investigation of 
all statements contained herein and understand that misrepresentations or 
omissions of facts called for is cause for rejection or expulsion 

A yearly subscription to Respiratory Care journol and AARC Times magozine 
includes an allocation of $11 50 from my dues for each of these publications 

NOTE: Contributions or gihs to the AARC are not lax deductible os cfiorifob/e 
contributions for income tax purposes. However, they may be lax deductible OS 
ordinary and necessary business expenses subject to restrictions imposed as a 
result of association lobbying activities The AARC estimates that the 
nondeductible portion of your dues — the portion which Is allocable to lobbying 
- IS 26% 




GRAND TOTAL = Membership Fee 

plus optional sections 

Total Amount Enclosed $_ 

n Please charge my dues (see below) 

To charge your dues, complete the following: 

G MasterCard 

D Visa 

Card Number 

Mail appiicafion and appropriate fees to: 
American Association for Respiratory Care • 11030 Abies Lone • Dallas, TX 75229-4593 • [972] 243-2272 • Fox [972] 484-2720 


Manuscript Preparation Guide 

R[:.spiRATOR'i' CARP: welcomes original nnmiiscripts related lo the sci- 
ence and technology of respiratoi^ care and prepared acci)rdiiig to the 
following instructions and the Unifonn RequiremeiilsforMcmusLripls 
Siihiiiillcil lo Biomedical .hmnuds (a\ailable at l\llp://\vww.icinje.(>rii/ 
index. Iilml). Manuscripts are blinded and reviewed by profession- 
als with experience in the subject of the paper. Authors are respon- 
sible for obtaining written [lennission from the original copyright hold- 
er to use pre\ iously published figures and tables. Before publication. 
authors receive page proofs and are allowed to make only minor cor- 
rections. Accepted manuscripts are copy-edited for clarity, concisiim. 
and consistency with Rkspir.^torv Care's format. Published 
papers are copyrighted by Daedalus Inc and may not be published else- 
where without permission. Editorial consultation is available at any 
stage of planning or writing: contact the Editorial Oftlce, 600 Ninth 
Avenue. Suite 702. Seattle WA 98104, (206) 223-0558. fa.x (206) 
223-0563. E-mail: 

Categories of Articles 

Research .\rticle: A report of an original investigation (a study). Must 
include; Title Page. .Abstract. Key Words. Introduction. Methods. 
Results. Discussit)n. Conclusions, and References. May also include: 
Tables, Figures (if so. must include Figure Legends). Acknowledg- 
ments, and Appendixes. 

Review: A comprehensive, critical review of the literature and state- 
of-the-art summary of a topic that has been the subject of at least 40 
published research articles. Must include: Title Page. Outline. 
Abstract. Key Words. Introduction. Review of the Literature. Sum- 
mary, and References. May also include: Tables. Figures (if so. must 
include Figure Legends), Acknowledgments, and Appendixes. 

Overview: A critical review of a pertinent topic that has fewer than 
40 published research articles. Same structure as Re\ iew Article. 

Update: A report of subsequent developments in a topic thai has been 
critically reviewed in RESPIRATORY CARE or elsewhere. Same stmc- 
ture as a Review Article. 

Special .Article: A pertinent paper not fitting one of the other cate- 
gories. Consult with the Editor before writing or submitting such a 

Editorial: A paper addressing an issue in the practice or administration 
of respiratory care. It may present an opposing opinion, clarify a posi- 
tion, or bring a problem into focus. 

Letter: A brief, signed communication responding to an item pub- 
lished in Respiratory Care or about other pertinent topics. 
Tables. Figures, and References may be included. The letter should 
be marked "For Publication." Report: Report of an uncommon clinical case or a new or 
improved method of management or treatment. A case-managing physi- 
ci;ui must either be an author or furnish a letter appniving the manuscript. 
Must include: Title Page. Abstract. Key Words. Introduction. Case 
SumiiKuy, Discussion, and References. May also include: Tables. Fig- 
ures (if so. must include Figure Legends), and Acknowledgments. 

Point-of-Vlew: A paper expressing personal but substantiated opinions 
on a pertinent topic. Must include: Title Page. Text, and References. May 
also include: Tables and Figures (if so. must include Figure Legends). 

Drug Capsule: A miniature re\ iew paper about a dnig or class of dnigs. 
Drag Capsules address phannacology. phannacokinetics. and/or phar- 

Graphics Comer: A brief, instractive case report discussing and illus- 
trating waveforms for monitoring or diagnosis. Must include: Ques- 
tions. Answers, and Discussion. 

PFT Corner: A brief, instructive case report arising from pulmonary 
function testing, accompanied by a review of the relevant physiolo- 
gy and appropriate references to the literature. Must include: Ques- 
tions. Answers, and Discussion. 

Test Your Radiologic Skill: A brief, instnictive case report pertinent 
to respiratory ciire and involving imaging, including one or more radio- 
graphs or other images submitted as black and w hite glossy photographs 
that clearly illustrate the teaching points being made. Must include: 
Questions, Answers, and Discussion. 

Preparing the Manuscript 

Double-space the text and number the pages. Do not include author 
names, author institutional affiliations, or allusions to institutional affil- 
iations anywhere except on the title page. On the Abstract page include 
the title but do not include author names. Begin each of the follow- 
ing on a new page: Title Page. Abstract, Text, Acknowledgments. Ref- 
erences, each Table, each Figure, and each Appendix. Use standard 
English in the first person and active voice. Type all headings in ini- 
tial-capital letters (eg. Introduction. Methods. Patients. Equipment. 
Statistical Analysis. Results. Discussion). Center the main section head- 
ings and place second-level headings on the left margin. 

Abstract. Please ensure that the abstract does not contain any facts 
or conclusions that do not also appe;ir in the body text. Limit the abstract 
to no more than 250 words. 

Key Words. Include a list of 6 to 10 key words or key phrases in 
Research Articles. Reviews. Overviews. Special Articles, and Case 
Reports. Key words are best selected from the Medical Subject Head- 
ings ( MeSH ) used by MF.DLINE and a\ ailable at lutpJ/wMw.ntm.nih. 

RESPIR.ATORY Care Manuscript Preparation Guide. Revised 4/01 

Manuscript Preparation Guide 

References. Assign referciKC numbers in the order lluit articles are 
cited in your manuscript. At the end of the manuscript, Hst the cited 
works in numerical order. Abbreviate journal names as in Index Medi- 
rus. List all authors. If the rese;irch has not yet been accepted for pub- 
licalion. cite the research as a personal communication (eg. 
Smith KR, personal coinmunication, 2(XJ1 ); however, you must obtain 
written permission fn >m the author to cite his or her unpublished data. 
Do not number such references; iiisieatl. make p;irenthetical reference 
in the body text of your manuscript. H,\ample: "Recently, Jones et al 
found this treatment effective in 4.S of 83 patients (Jones HI, personal 
communication. 2000)." 

Corporate author book: 

American Medical Association Department of Drugs. AMA 
drug evaluations, 3rd ed. Littleton CO: Publishing Sciences 
Group: 1977. 

Chapter in book with editor(s): 

Isono S. Upper airway muscle function during sleep. In: Lough- 
lin GM. Carroll JL. Marcus CL, editors. Sleep and breathing in 
children: a deselopmental approach. (Lung Biology in Health and 
Disease, Vol 147, Claude Lenfant, Executive Editor.) New 
York/Basel: Marcel Dekker. 2000:261-291. 

The following examples show Re.spiratory Care's style 
for references. 

Paper accepted but not yet published: 

Hess D. New therapies for asthma. Respir Care (year, in press). 

Article in a journal carrying pagination throughout the volume: 
Legere BM. Kavuru MS. Pulmonary function in obesity. 
Respir Care 200O;45(8):967-968. 

Article in a publication that numbers each issue beginning with Page 1 : 
Kallstroni TJ. Focus on asthma — disease management: a role for 
the respiratory therapist. AARC Times 1999;23(Oct):16, 17, 19. 

Corporate author journal article: 

American Association for Respiratory Care. Clinical Practice 
Guideline. Removal of the endotracheal tube. Respir Care 

Article in journal supplement: (Joumals differ in numbering and iden- 
tifying supplements. Supply information sufficient to allow retrieval.) 
Barnes PJ. Endogenous inhibitory mechanisms in asthma. Am 
J Respir Cm Care Med 2000; 161(3 Pt 2):SI76-S181. 

Abstract in journal: (Abstracts citations are to be avoided, and those 

more than 3 years old should not be cited.) 

Volsko TA. De Fiore J, Chatbuni RL. Acapella vs flutter: per- 
formance comparison (abstract). Respir Care 20O0;45(8):991. 

World Wide Web 

Aniericiin Lung Association. Trends in pneumonia, influenza, and 
acute respiratory conditions mortality and morbidity. February, 2(X)0. Accessed November 20. 2000. 

Tables. Tables should be consecuti\ ely numbered. .\[ the bottom 
of the table define and/or explain all abbreviations and symbols used 
in the table. For footnotes use the follow ing symbols, superscripted, 
in the table body, in the following order: *, t, +, S, ||.f. **. tt. If 
data include a "±" value, please indicate whether the value is a stan- 
dard deviation or standard error of the mean 

Figures (illustrations). Figures include graphs, line drawings, pho- 
tographs, and radiographs. All figures should be sharp black-and- 
white images and be camera-ready. Glossy prints are preferred, but 
a good laser print will do. Use only illustrations that clarify and aug- 
ment the text. Radiographs should clearly illustrate the point being 
made and should be submitted as black-and-white glossy photographs. 
If color is essential to the figure, consult the Editorial Office for 
more information. In reports of animal experiments, use schemat- 
ic drawings, not photographs. A letter of consent must accompa- 
ny any photograph of an identifiable person. Number figures con- 
secutively as Figure 1, Figure 2, etc. All the figures must be mentioned 
in the text. Every figure must have a legend (a title and/or descrip- 
tion explaining the figure). Figure legends should appear as sep- 
arate paragraphs at the end of the manuscript (after the References 
section), in the same computer file as the manuscript (not in a sep- 
arate file, as w ith the tables and figures). 

Editorial in a journal: 

Giordano SP. What's that sound? (editorial) Respir Care 
2()00;4.';(10):1 167-1 168. 

Editorial w ith no author given: 

The perils of paediatric research (editorial). Lancet 
1 999:353(9 154):68.'S. 

Letter in journal: 

Piper SO. Testing conditions for nebuli/ers ( letter). Respir Care 

Do not cieate scanned versions of figures bomiwed from other pub- 
lications; clear photocopies are preferable. To include figures pre- 
viously published in other publications you must obtain permission 
from the original copyright holder. Figures must be of professional 
qualitv and a copv of the article from which the ligure came should 
be available. 

Drugs. Precisel\ identify all dmgs and chemicals used, giving gener- 
ic (nonproprietary) names, doses, and methods of adnunisiralion. 
Brand or trade names may be gi\ en in parentheses after generic 

Book; (For any book, specific pages should be cited whenever ref- 
erence is made to specific statements or other content.) 

Cairo JM. Pilbeam SP. Mosby"s respiratory care equipment, 6th 

ed. St Louis: Mo.sbv; 1999:76-85. 

Commercial Products. In the text, parenthetically identify com- 
mercial products only on first mention, giving the manufacturer's 
name and location. Example: "We performed spirometry (1085 Sys- 
tem, Medical Graphics, Minneapolis. Minnesota)." Provide model 

Respiratory Care Manuscript Preparation Guide. RcMsed 4/01 

Manuscript Preparation Guide 

numhcrs II asailahk'. and manufacturer's suggested price illlic stiidv 
has cost implications. 

Permissions: You must obtain \s ritten permission to use pictures 
of identifiable individuals or Co name individuals in the Acknowl- 
edgments section. V'ou must obtain written permission from the 
original copyright holder to use figures or tables from other pub- 
lications. Copies of all applicable permissions must be on file at 
RESPIRATOR')' Care before a manuscript goes to press. Copyright 
is most often held by the journal or book in which the figure or table 
originally appeared and applies to the creativity, style, and form 
in which the facts/data are presented to the reader: the facts them- 
selves are not eopvTight-protectable. Therefore, pennission is rei|uired 
to reproduce a table or figure directly, or u ith minor adaptations, 
from a journal or book, but permission is not required if data arc 
extracted and presented in a new format. In that case, cite the source 
of the data as in the following example: "Adapted from Reference 

Ethics. When reporting experiments on hummi subjects, indicate that 
procedures were conducted in accordance with the ethical standards 
of the World Medical Association Declaration nj Helsinki {see Respir 
Care l997;42(6):635-636: also available at littp./ 
l7-c_eparafiraphnumherinfi.html) or of the institution's committee 
on human experimentation. State that informed consent was 
obtained. Do not use patients" names, initials, or hospital numbers in 
text or illustrations. When reporting experiments on animals, indicate 
that the institution's policy, a national guideline, or a law on the care 
and use of laboratory animals was followed. 

Statistics. Identify the statistical tests used in analyzing the data and 
give the prospectively determined level of significance in the Meth- 
ods section. Report p values in the Results section. Cite only textbook 
and published article references to support choices of tests. Paren- 
thetically identify any computer programs used. If data include a "±" 
value, please indicate whether the value is a standard deviation or stan- 
dard error of the mean. 

Units of Measurement. Express all measurements in .SI (Systenie Inter- 
nationale) units (units and conversion factors listed at Respir Care 
I997;42(6):640 and also available at 
uuthor_guide/. Show gas pressures (including blood gas tensions) m 
millimeters of mercury (mm Hg). 

Conflict of Interest. On the cover page, authors must disclose any 
liaison or tlnancial arrangement they have with a manufacturer or 
distributor w ht)se product is addressed in the manuscript or with the 
manufacturer or distributor of a competing product. Such arrange- 
ments do not disqualify a paper from consideration and are not dis- 
closed to reviewers. Reviewers are screened for possible conllict of 

Abbreviations and Symbols. Use the standard abbreviations and 
symbols listed at Respir Care l997:42(6):637-642 (also available 
at Do not create new 
abbreviations. Do not use abbreviations in the title or section head- 
inas and do not use unusual abbreviations in the abstract. Use an 

abbiev iaiion only if (he term occurs 4 or more limes in (he paper. 
Parenthetically dcline all abbrev iations: \\rile out (he full term on 
first mention, followed by the abbicvialion in parentheses. 
Example: chronic obstructive pulmonary disease (COPD). There- 
after use only the abbreviation. Standard units of measurement and 
scientific tenns can be abbreviated without explanation (eg, L/min, 
mm Hg. pH. Oi). 

Please use the following forms: cm lUC) (nol ciiiH2()). r(not bpni). 
L (not 1). l./min (not LPM. l/min. or Ipiii). mL (not ml), mm Hg (not 
mniHg). pH (not Ph or PH ). p > ().(K)I (not p>().(X)l ). s (not sec), Sp02 
(arterial oxygen saturation measured \ la pulse-oxmietry). 

Prior and Duplicate Publication. In general, do nol submit work that 
has been published or accepted elsewhere, though in special 
instances the Editor may consider such material if the original pub- 
lisher grants pennission. Please consult the Editor before submitting 
such work. 

Authorship. All persons listed as authors must have participated in 
the reported work and in the shaping of the manuscript, all must have 
proofread the submitted manuscript, and all should be able to pub- 
licly and defend the paper's content. A paper of corporate author- 
ship must specify the key persons responsible for the article. Attri- 
bution of authorship is not ba,sed solely on solicitation of funding, 
collection or analysis of data, provision of advice, or similar services. 
Persons who provide such ancillaiy serv ices may be recognized in an 
Acknowledgments section, but written permission is required from 
the persons acknowledged. 

Reviewers: Please supply the names, credentials, affiliations, address- 
es, and phone/fax numbers of 3 professionals whom you consider expert 
on the topic of your paper. Your manuscript may be sent to one or 
more of them for blind peer review. 

Subniittln;; the Manu.script 

Submit 3 printed copies and one (3.5-inch) computer diskette. The 
printed copies should each include photocopies of all of the Figures, 
Tables, and Appendixes. On the diskette, the manuscript should be 
in one file and the tables in a separate file. If soft copies of the fig- 
ures are available, they .should also be in a separate file. However, do 
not create scanned versions oj figures l^orrowedfrom other publications: 
clear photocopies are preferable. Include the completed Cover Let- 
ter and Checklist (see next page I and pennission letters. Mail to RES- 
PIRATORY Care. 600 Ninth Avenue. Suite 702. Seattle WA 98104. 
Do not fax manuscripts. Receipt will be acknowledged. 

Respiratory Care 
Editorial Office: 

600 Ninth Avenue. Suite 702 
Seattle W AW 1 04 

(206) 223-0558 (voice) 

(206) 223-0563 (fax) 


Respir.'KTORV Care Manuscript Preparation Guide, Revised 4/01 

Cover Letter & Checklist 

A copy of this completed form must accompany all manuscripts submitted for publication. 

Title of Paper: 

Publication Category: _ 
Corresponding Author: 
Mailing Address: 

Reprints: □ Yes □ No 



E-mail Address: 

"We, the undersigned, have all participated in the work reported, proofread the accompanying manuscript, and approve its sub- 
mission for publication," Please print and include credentials, title, institution, academic appointments, city and state. If more 
than 4 authors, please use another copy of this form.* 

'First Author: 

'Second Author: 

•Third Author: 

Author Signature/Date. 

Author Signature/Date, 

Author Signature/Date, 

'Fourth Author: 

Author Signature/Date. 

Has this research been presented in any public forum? □ Yes □ No 
If yes, where, when and by whom? 

Has this research received any awards? lJ Yes ^ No 
If yes, please describe. 

Has this research received any grants or other support, financial or material? □ Yes 3 No 
If yes, please describe. 

Do any of the authors of this manuscript have a financial Interest in (or a commercial or consulting relationship to) any of the 
products or manufacturers mentioned in this paper or any competing products or manufacturers? ^ Yes □ No 

If yes, please describe. 

i_J Have you enclosed a copy of the manuscript on diskette? 

^ Is double-spacing used throughout entire manuscript? 

□ Are all pages numbered in upper-right corners? 
_i Are all references, figures, and tables cited in the text? 
LJ Has the accuracy of the references been checked, and are they correctly formatted? 

□ Have SI values been provided? 
^ Has all arithmetic been checked? 
^ Have generic names of drugs been provided? 
_| Have necessary written permissions been provided? 
_| Have authors' names been omitted from text and figure labels? 
_| Have copies of 'in press' references been provided? 
L_l Has the manuscript been proofread by all the authors? 
_! Have the manufacturers and their locations been provided for all devices and equipment used? 

Rl SPIK.MUR'I' C,^RE Manu.script Prcparulioii Guide. Rc\ ised 4/01 


Notices of compclilions, scholarships, t'cllowships. cxaininallon dales, new educalional pro^'rains. 

and ihc like will he listed here Iree o! charge. Items lor the Notices section must reach the Journal 60 days 

belorc the desired month ot puhlication (Januar\ I lor the March issue. Februai-> I lor the April issue, etc). Include all 

pertinent mfomialion and mail notices to Rt-.Sl'lKAIORY CaRH Notices Dept. I \0M) Abies I.ane. Dallas TX 7522*)-4593. 

T^auKcCi 2002 

Withholding and Withdrawing Life Support in 

the ICU — Gordon D Rubenfeld MDMSc / 
Richard D Branson BA RRT FAARC — Videotape 

Weaning from Mechanical Ventilation: New 
Insights. New Guidelines — Neil R Machityre 
Videotape A\ ailahle 

Neonatal and Pediatric Ventilators: What's the 
Difference? — Mark J Heulitt MD FAARC/ 
Richard D Branson B A RRT FAARC — Videotape 

Ventilator Graphs: What's With That Wave? — 

Jon O Nilsestuen PhD RRT FAARC/ Richard D 
Branson BA RRT FAARC — Videotape Available 

Talking w ith Patients and Families About 
Death and Dying — Helen M Sorensen MA RRT 
FAARC/ David J Pierson MD FAARC — 
Videotape Available 

Pressure vs Volume Ventilation: Does It Matter? 

— Robert S Campbell RRT FAARC/ Richard D 
Branson BA RRT FAARC — Live September 10/ 
Audio October 8 

Inpatient Management of COPD — Randall 
Rosenblatt MD/ David J Pierson MD FAARC — 
Live October 22: Audio November 12 

High-Frequency Oscillatory Ventilation — 

Thomas E Stewart MD/ Richard D Branson BA 
RRT FAARC — Live November 19; Audio 
December 10 

Helpful LUeb.Sites 

American Association for Respiratory Care 


— Current job listings 

— American Respiratory Care Foundation 
tellowships, grants, & awards 

— Clinical Practice Ctiidelines 

National Board for Respiratory Care 


— Subject and Author Indexes 

— Contact the editorial staff 

— Open FORUM; submit your abstract online 

Asthma Management 
Model System 

Keys to Professional Excellence 

Committee on Accreditation for Respiratory Care 

The National Board for Respiratory Care — 
Examination F"ees for 2002 






Examination Fees 

$190 (new appiiciint) 

$230 (new applicant) 
$220 (reapplicant) 

$200 (new applicant) 
$170 (reapplicant) 

$250 (new applicant) 
$220 (reapplicant) 

RRT $ 1 90 ( new i S 1 50 ( reapplicant ) wrillen only 

(Written $200 (new and icapplicanl) CSE onl\ 

& CSE) $390 (new) $350 (reapplicant) both' 

For int'orniation about other ser\ ices or fees, write to the 

National Board lor Respiratorv Care. 

83l()Nieinaii Road. I.encxa KS 66'2I4. or call 

mM .^W-4:()(). FAX (9l3l .*141-()l.^6. 

ore-mail: nbTC-inloC" iihrc.ora 

RESPIRATORY Care • September 2002 Vol 47 No 9 


Not-for-profil organii'.ations are offered a free advertisement of up to eight lines to appear, on a space-available 

basis, in Calendar of F.venls in RE.S1'IRAT0RY CARE. Ads for other meetings are priced at $50 for members and $60 for nonmembers and 

require an insertion order. Deadline is the 20th of the month two months preceding the month in which you wish the ud to run. 

Submit copy ^uid insertion orders to Calendar of Events. RESPIR.vroRY CARE. I lO.M) Abies Lane. Dallas T.\ 7.'i2:9-4.'i93. 

of Events 


AARC & State Society Programs 


Sept. 5-7 

TSRC North Region - Pineywootds District 
16th Annual Fall Seminar; Lufkin, TX 

Pam Mollis (409) 639-7006 

Sept. 10 

Professor's Rounds 2002 Live Vitdeoconference, 
Pressure versus Volume Ventilation: Does It Matter? 

AARC, (972) 243-2272 

Sept. 17 

Professor's Rounds 2002 Teleconference, 

Talking with Patients and Families about Death and Dying 

AARC, (972) 243-2272 

Sept. 19-20 

Kansas Respiratory Care Society 
Western Kansas Conference; Hays, KS or 

e-mail Julia Downs at 

Oct. 4 

Indoor Environmental Triggers and 

the RT Train-the-Trainer Workshop, Tampa, PL 

AARC, (972) 243-2272, 

Oct. 5-8 

AARC 48th International Respiratory Congress; Tampa, FL 

AARC, (972) 243-2272, 

Oct. 8 

Professor's Rounds 2002 Teleconference, 
Pressure versus Volume Ventilation: Does It Matter? 

AARC, (972) 243-2272 

Oct. 16 

Ninth Annual Southern Colorado Pulmonary Medicine 
Symposium; Pueblo, CO 

Southern Chapter of the CSRC; 
Barry Beard, 

Oct. 22 

Professor's Rounds 2002 Live Videoconference, 
Inpatient Management of COPD 

AARC, (972) 243-2272 

Nov. 12 

Professor's Rounds 2002 Teleconference. 
Inpatient Management of COPD 

AARC. (972) 243-2272 

Nov. 19 

Professor's Rounds 2002 Live Videoconference, 
High-Frequency Oscillatory Ventilation 

AARC, (972) 243-2272 

Dec. 10 

Professor's Rounds 2002 Teleconference, 
High Frequency Oscillatory Ventilation 

AARC, (972) 243-2272 


Other Meetings 


Sept. 19 

Fourth Annual Rainbow Babies & Children's 
Pediatric/Neonatal Respiratory Conference, 
Independence, OH 

UHHS Respiratory Care Dept. (330) 322-4513 

Oct. 24-26 

21st Annual Recent Advances in Pulmonary and 
Critical Care Medicine, San Francisco, CA 

Claire Silver at 

Nov. 13-16 

27th Annual Neonatal International Symposium, 
University of Miami School of Medicine, 
Key Biscayne, FL 

Mana Valles, (305) 585-6408 or 

Nov. 15 

Duke University Medical Center's 
Fall Seminar 2002. Durham, NO 

Respiratory Care Services. (919) 681-2720. 
or Bob Campbell at 


Rfspirator'i- Care • .September 2002 Vol 47 No 9 


in This Issue 

Abdul-Khaliq. Hashim 998 

Becker. Michael A 994 

Carmichaci. Tina B 1002 

Chatburn. Robert L 1018 

Cullen, Deborah L 986 

Dechert. Ronald E 994 

Donn. Steven M 994 

Ewert. Peter 998 

Fahy. Bonnie 1025 

Granger. Wesley M 1028 

Hess. Dean R 1007 

Het/er. Roland 998 

Hill. Thomas V 1021 

Hlaslala. Michael P 1028 

Hopper, Keith B 1018 

Kretschmar. Oliver 998 

Lange. Peter E 998 

Mishoe. Shelley C 1021 

Oca, Melisa J 994 

Roberts. Glenn A 1018 

Rodak. Bernadette 986 

Roth. Stephen J 1002 

1026. 1027 

Stern. Eric J 

Thoongsuwan. Nisa 1027 

Walsh. Edward P 1002 

Wilkins. Robert L 1024 

Yigitbasi, Mustafa 998 

Zurbrugg, Heinz R 998 

in This Issue 

To ad\ertise in RKSI'lk A I'OR^ ("ARK. contact Tim Goldsbur>, Director, Advertising; Sales, e-niail: goldsburi ("'aarc.orj; for rates 
and media information. Contact Karen Camlet. Advertising Representative, e-mail: camletC'' aarc.orj;. for recruitment/classilied 
advertisinj;. Sales oiVice: .Wll lequesta Drive, lequesta, FI. J.M6M. Telephone: 561-74.'i-ft7M.1. Fa\: 56I-745-67M5. 

.Send production niattrtials for A.\RC publications to Binkle.v teaarcorg or AARC. 1 1(1.111 Abies Lane, Dallas I'X 75229-4593 
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